What is the recommended topical steroid treatment for psoriasis?

Recommended Topical Steroid Treatment for Psoriasis

For plaque psoriasis not involving intertriginous areas, class 1 (ultrahigh-potency), class 2 (high-potency), or class 3-5 (medium-potency) topical corticosteroids are recommended for up to 4 weeks as initial therapy. 1, 2

Selection of Topical Corticosteroid by Potency and Location

Body Location Considerations

• Trunk and extremities (non-intertriginous): Use class 1-5 (medium to ultrahigh potency) corticosteroids 1
  • For thick, chronic plaques: Class 1 (ultrahigh-potency) corticosteroids 1
  • For moderate plaques: Class 2-3 (high to medium-high potency) corticosteroids 1, 2
• Face, intertriginous areas, and thin skin: Lower potency corticosteroids (class 5-7) to minimize adverse effects 1, 2
• Scalp psoriasis: Any potency (class 1-7) topical corticosteroids for a minimum of up to 4 weeks 1

Specific Corticosteroid Options by Potency

• Ultrahigh-potency (Class 1):

  • Clobetasol propionate 0.05% (cream, ointment, gel) 3
  • Halobetasol propionate 0.05% 1
  • Betamethasone dipropionate 0.05% (augmented) 1
  • Diflorasone diacetate 0.05% 1

• High-potency (Class 2):

  • Fluocinonide acetonide 0.5% 1
  • Amcinonide 0.1% 1
  • Betamethasone dipropionate 0.05% 1

• Medium-potency (Class 3-5):

  • Triamcinolone acetonide 0.1% 1, 4
  • Fluticasone propionate 0.005% 1
  • Mometasone furoate 0.1% 1

Duration and Application

• Standard duration: Up to 4 weeks for initial treatment 1, 2
• Application frequency: Apply a thin layer to affected areas 1-2 times daily 4, 5
• Maximum amount: For ultrahigh-potency corticosteroids (clobetasol, halobetasol), do not exceed 50g per week 3
• Extended use: Treatment beyond 4 weeks (up to 12 weeks) should only be done under careful physician supervision 1, 2

Tapering and Maintenance

• Gradually reduce frequency of application after clinical improvement to avoid rebound flares 1, 2
• Consider weekend-only application for maintenance therapy after initial control 6
• For chronic management, consider rotation or combination with steroid-sparing agents 1, 6

Special Considerations

• For facial and intertriginous psoriasis: Consider topical calcineurin inhibitors (tacrolimus 0.1%) as steroid-sparing agents 1
• For thick, resistant plaques: Consider intralesional triamcinolone acetonide (up to 20 mg/mL) every 3-4 weeks 1
• For scalp psoriasis: Use appropriate vehicle (solutions, foams, or shampoos) for better penetration 5

Monitoring for Adverse Effects

• Watch for skin atrophy, striae, telangiectasia, and purpura, especially on face, intertriginous areas, and forearms 1, 2
• Monitor for signs of systemic absorption with prolonged use of high-potency steroids 2
• Avoid abrupt discontinuation to prevent rebound flares 1, 2

Common Pitfalls to Avoid

• Using high-potency steroids on face or intertriginous areas 1, 2
• Continuous use beyond recommended duration without physician supervision 2, 3
• Failure to taper after clinical improvement 1, 2
• Occlusive dressings with high-potency steroids (increases absorption and risk of adverse effects) 3, 4
• Inadequate patient education about proper application technique and quantity 5