What is the recommended treatment for perianal psoriasis?

Treatment of Perianal Psoriasis

For perianal psoriasis, use low-potency topical corticosteroids (class 6-7) as first-line therapy, avoiding high-potency agents due to the high risk of skin atrophy in this intertriginous area. 1

Initial Treatment Approach

• Low-potency topical corticosteroids should be applied to perianal psoriasis because intertriginous areas are highly susceptible to steroid-induced atrophy and other adverse effects 1
• The perianal region is classified as a "vulnerable area" that warrants consideration for systemic therapy even with limited body surface area involvement if symptoms (pain, bleeding, itching) are present 1
• Treatment duration should be carefully monitored, with regular clinical review and no unsupervised repeat prescriptions 2

Alternative and Combination Topical Options

• Topical tacalcitol ointment or calcipotriene combined with low-dose hydrocortisone can be used for 8 weeks as an alternative approach for facial and intertriginous psoriasis 1
• Vitamin D analogs (calcipotriene) should be considered, though they may cause local irritation in sensitive areas 1
• Topical immunomodulators (tacrolimus, pimecrolimus) are effective alternatives for intertriginous psoriatic lesions and avoid the atrophy risk of corticosteroids 3, 4

Critical Safety Considerations

• Never use high-potency (class 1-3) corticosteroids on perianal skin due to rapid absorption and high risk of skin atrophy, striae, and systemic absorption in this occluded area 1
• Avoid anthralin on flexures and intertriginous areas due to severe irritation and staining 1
• Do not combine salicylic acid with calcipotriene, as the acidic pH inactivates calcipotriene 1

When to Escalate Treatment

• If topical therapy fails or symptoms significantly impact quality of life, consider systemic therapy including phototherapy, traditional DMARDs (methotrexate, cyclosporine), or biologic agents (TNF inhibitors) 1
• The presence of symptomatic perianal psoriasis (pain, bleeding, itching) qualifies patients for systemic therapy consideration regardless of limited body surface area 1
• TNF inhibitors (infliximab, adalimumab, etanercept) have demonstrated efficacy for both skin and potential concurrent joint manifestations 1

Practical Application Strategy

• Apply low-potency corticosteroid once or twice daily for 2-4 weeks initially 1
• Transition to intermittent therapy (every-other-day or weekend-only application) for maintenance to minimize adverse effects 3
• Consider alternating with vitamin D analog or topical immunomodulator for long-term management 1, 3
• Avoid injection through psoriatic plaques if considering intra-articular therapy for concurrent arthritis 1