What are the first line treatments and home care advice for patients with psoriasis or eczema?

Treatment and Home Advice for Psoriasis and Eczema

Psoriasis First-Line Treatment

For mild psoriasis (<5% body surface area), start with combination therapy using a high-potency topical corticosteroid (class 2-5) plus vitamin D analog (calcipotriene) applied once daily for up to 4 weeks, as this provides superior efficacy compared to either agent alone. 1, 2

Topical Corticosteroid Selection by Location

• Trunk and extremities: Use moderate-to-high potency corticosteroids (class 2-5) for maximum 4 weeks 2
• Face, genitals, and skin folds: Use only low-potency corticosteroids or switch to tacrolimus 0.1% to avoid skin atrophy 1, 2
• Scalp: Use clobetasol propionate 0.05% shampoo twice weekly, leaving on for 5-10 minutes before rinsing, for up to 4 weeks maximum 3
• Thick plaques: Start with ultra-high potency (class 1) corticosteroids under dermatology supervision 4, 2

Critical Corticosteroid Safety Rules

• Never exceed 100g of moderate-potency corticosteroid per month 4, 2
• Require regular clinical review every 4 weeks during active treatment 4, 3
• Never provide unsupervised repeat prescriptions 4, 2
• Plan annual periods using alternative non-corticosteroid treatments to prevent tachyphylaxis 4, 2
• Taper frequency gradually after improvement rather than abrupt cessation to prevent rebound flare 3

Alternative Topical Agents for Psoriasis

• Coal tar: Start with 0.5-1.0% crude coal tar in petroleum jelly, increase every few days to maximum 10% if tolerated 4
• Dithranol (anthralin): Begin at 0.1-0.25% concentration, double the concentration as tolerated, using "short contact mode" (15-45 minutes daily) to minimize irritation and staining 4
• Vitamin D analogs alone: Use calcipotriene up to 100g per week maximum to avoid hypercalcemia 1
• Tazarotene: Combine with moderate-to-high potency corticosteroids to reduce irritation 2

Maintenance Strategy for Psoriasis

After initial 4-week treatment achieves control, switch to weekend-only corticosteroid application while using vitamin D analogs on weekdays 2. For scalp psoriasis, transition to ketoconazole 2% shampoo once weekly after completing corticosteroid course 3.

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Eczema (Atopic Dermatitis) First-Line Treatment

For atopic eczema, apply emollients liberally 1-3 times daily as the foundation of therapy, combined with mildly potent corticosteroids for children or moderately potent corticosteroids for adults during flares. 4, 3

Emollient Application Technique

• Apply emollients in the direction of hair growth to reduce folliculitis risk 4
• Use impermeable or semi-permeable films over emollients to enhance penetration 4
• Continue emollients even when skin appears clear to maintain barrier function 3

Corticosteroid Selection for Eczema

• Children: Use mildly potent corticosteroids as first-line 4
• Adults: Use moderately potent corticosteroids as first-line 4
• Sensitive areas (face, flexures, genitalia): Use low-potency corticosteroids or topical calcineurin inhibitors 4
• Severe flares: May require brief course of potent corticosteroids under specialist supervision 4

Adjunctive Measures for Eczema

• Sedating antihistamines at bedtime: Use large doses if needed to control nocturnal scratching; avoid daytime use 4
• Wet wrap therapy: Apply emollients under damp bandages for severe flares 4
• Avoid irritants: Identify and eliminate contact with soaps, detergents, and other triggers 5

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Home Care Advice for Both Conditions

Medications That Worsen Psoriasis (Must Avoid)

• Lithium, chloroquine, and mepacrine: Can cause severe, life-threatening psoriasis deterioration 4, 2
• Beta-blockers and NSAIDs: May precipitate or worsen psoriasis in susceptible patients 4, 2
• Systemic corticosteroids: Absolutely avoid as they cause severe rebound flares upon discontinuation 4, 2, 6
• Alcohol: Known trigger for psoriasis exacerbations 4

Application Instructions

• Apply topical treatments to damp skin immediately after bathing to enhance absorption 4
• Use enough medication: Most patients under-apply topicals, reducing efficacy 4
• Do not mix salicylic acid with calcipotriene: The acidic pH inactivates vitamin D analogs 2
• Apply vitamin D analogs after phototherapy, not before: UV light inactivates these medications 1

When to Seek Specialist Referral

• Diagnostic uncertainty 4
• Failure to respond to first-line topical therapy after 4-6 weeks 4, 3
• Body surface area >5% or involvement of vulnerable areas (face, hands, feet, genitals) 4
• Symptoms causing significant pain, bleeding, or quality of life impairment 4
• Signs of erythrodermic or pustular psoriasis 3
• Need for second-line treatments (phototherapy, systemic agents) 4

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Common Pitfalls to Avoid

The most common treatment failure is inadequate patient adherence due to poor understanding of application technique and unrealistic expectations about speed of response. 4, 2 Corticosteroids show improvement within 2 weeks, but vitamin D analogs require 6-8 weeks for full effect 7. Perceived "tachyphylaxis" to corticosteroids is usually poor adherence rather than true receptor down-regulation 2.

Long-term use of potent topical corticosteroids causes skin atrophy, striae, telangiectasia, and potential HPA axis suppression, particularly on the face and intertriginous areas 1, 6. Maximum treatment duration with high-potency agents is 4 weeks 3, 2.

Patients often fail to apply sufficient quantities of topical medications, leading to suboptimal outcomes 4. Reinforce proper application technique at every visit.