How to manage itching without plaques in psoriasis?

Managing Itching Without Plaques in Psoriasis

For itching without visible plaques in psoriasis, use liberal emollients 1-3 times daily as first-line therapy, combined with low-potency topical corticosteroids (hydrocortisone 1%) applied once daily for 2-4 weeks maximum during symptomatic periods. 1, 2

First-Line Approach: Emollients as Foundation

• Emollients are the cornerstone of managing pruritus in psoriasis without active plaques, as they retain moisture in the stratum corneum, reduce itching and desquamation, and help prevent quick relapse when other treatments are discontinued 1, 2
• Apply emollients 1-3 times daily to all affected areas, with particular benefit from applying a thin coat of petrolatum after bathing 1, 2
• An RCT demonstrated that combining emollients with topical corticosteroids improved symptoms more than corticosteroids alone after 4 weeks 1, 2

Adding Anti-Inflammatory Treatment for Persistent Itch

• When emollients alone are insufficient, add low-potency topical corticosteroids (hydrocortisone 1%) once daily for 2-4 weeks maximum 3, 4
• After initial control, taper to every-other-day or weekend-only application to maintain symptom control while minimizing adverse effects 3, 5
• Never use unsupervised repeat prescriptions of corticosteroids, and limit to maximum 100g of moderate-potency preparation per month with regular clinical review every 4 weeks 1, 6

Steroid-Sparing Alternatives for Chronic Management

• Tacrolimus 0.1% ointment is an excellent steroid-sparing option for chronic itch management, particularly effective for sensitive areas like face and intertriginous regions, with 89% response rate in managing periocular inflammatory conditions 3, 7
• Apply tacrolimus once daily to affected areas; warn patients about initial burning sensation that typically improves with continued use 3, 2
• Vitamin D analogues (calcipotriene/calcitriol) can be added in the evening if tolerated, though they are less effective for itch than for visible plaques 1

Treatment Algorithm

1. Start with emollients alone applied 1-3 times daily for all patients with itching 2
2. If inadequate after 1-2 weeks, add hydrocortisone 1% ointment once daily 3, 4
3. After 2-4 weeks of corticosteroid use, taper to intermittent application (every-other-day or weekends only) 3, 5
4. For chronic maintenance, transition to tacrolimus 0.1% ointment once daily as steroid-sparing agent 3, 7
5. Continue emollients throughout all phases of treatment 2, 8

Critical Monitoring and Precautions

• Schedule regular clinical review every 4 weeks during active corticosteroid treatment to assess response and monitor for skin atrophy, particularly on face and intertriginous areas 1, 6
• Plan annual periods using alternative non-corticosteroid treatments to minimize long-term corticosteroid exposure 1, 6
• When using tacrolimus on eyelids or periocular areas, arrange ophthalmology review within 4 weeks and refer immediately if eye pain or vision changes develop 3

Common Pitfalls to Avoid

• Never use potent or superpotent corticosteroids for itch without visible plaques, as the risk of skin atrophy far outweighs benefits 3, 9
• Avoid continuous daily corticosteroid application even with low-potency agents; always plan for tapering and intermittent use 3, 5
• Do not abruptly discontinue corticosteroids after prolonged use; taper frequency gradually to prevent rebound flare 6, 5
• Avoid combining salicylic acid with calcipotriene as this causes instability 1

Additional Therapeutic Options

• Coal tar products and topical salicylates may provide antipruritic benefit, though coal tar is no better than placebo for visible plaques 7, 9
• Menthol, pramoxine, or capsaicin can be considered as adjunctive antipruritic agents 7
• For refractory cases, consider phototherapy (narrowband UVB) or systemic agents like methotrexate or biologics, though these are rarely needed for itch alone 7, 10

Patient Education Points

• Explain that psoriasis is chronic and requires long-term management with intermittent therapy rather than continuous treatment 3, 8
• Emphasize the importance of maintaining skin barrier function through regular emollient use, even when symptoms improve 2, 8
• Counsel about friction and irritation playing a significant role in triggering symptoms (Koebner phenomenon), and advise gentle skin care 1, 8
• Warn about potential for skin atrophy and telangiectasia with prolonged corticosteroid use, even with low-potency agents 3, 5