What is the recommended cream for treating psoriasis?

Recommended Cream for Psoriasis

For mild to moderate plaque psoriasis, use a combination product containing calcipotriene (vitamin D analog) plus betamethasone dipropionate (potent corticosteroid) applied once daily for 4 weeks, which provides superior efficacy compared to either agent alone. 1

First-Line Treatment Algorithm

For Body/Limb Psoriasis (Non-Facial, Non-Intertriginous)

Start with combination therapy:

• Calcipotriene/betamethasone dipropionate combination product (fixed combination) once daily for 4 weeks is the most effective topical option 1, 2
• This combination achieves maximal improvement within 2-4 weeks in the majority of patients 3
• The fixed combination product is more convenient than separate applications and reduces the risk of inactivation 1, 3

Alternative initial regimens if combination product unavailable:

• Apply high-potency topical corticosteroid (Class II-III) in the morning AND vitamin D analog (calcipotriene) in the evening 1
• Use medium to high-potency corticosteroids (Class II-V) twice daily for 2-4 weeks maximum 2, 4

After initial 4-week treatment period, transition to maintenance:

• Apply high-potency corticosteroid twice daily on weekends only 1
• Apply vitamin D analog (calcipotriene) twice daily on weekdays 1, 4
• This weekend-only corticosteroid regimen reduces adverse effects while maintaining efficacy 1

For Facial and Intertriginous Psoriasis

Use low-potency agents to avoid skin atrophy:

• First-line: Tacrolimus 0.1% ointment twice daily for 8 weeks (65% achieve clear/almost clear skin) 2
• Alternative: Pimecrolimus 0.1% cream twice daily for 8 weeks (71% efficacy) 2
• Alternative: Calcipotriene combined with hydrocortisone for 8 weeks 1
• Calcineurin inhibitors (tacrolimus, pimecrolimus) are preferred because they do not cause skin atrophy, unlike corticosteroids 2, 4

For Scalp Psoriasis

Recommended formulations:

• Calcipotriene foam plus betamethasone dipropionate gel for 4-12 weeks 1
• Superpotent corticosteroids (Class I) like clobetasol propionate 0.05% for up to 4 weeks 2, 4
• Use foam or solution formulations for easier application and better penetration 1

For Palmoplantar Psoriasis

• High-potency corticosteroids (Class I-II) are needed due to thick skin 5
• Vitamin D analogs can be added for combination therapy 1, 5

Corticosteroid Potency Selection by Location

Match potency to body site and disease severity:

• Superpotent (Class I): Thick plaques on body/limbs, palms/soles - maximum 2-4 weeks continuous use 1, 2
• Potent (Class II-III): Body/limb psoriasis - 68-72% efficacy rates 1, 2
• Mid-strength (Class IV-V): Less severe body psoriasis 1
• Low-potency (Class VI-VII): Face, intertriginous areas, children - to prevent skin atrophy 2, 4

Critical Combination Therapy Considerations

Synergistic combinations that enhance efficacy:

• Vitamin D analogs combined with corticosteroids provide synergistic effects superior to monotherapy 1, 6, 3
• Tazarotene 0.1% combined with medium/high-potency corticosteroids for 8-16 weeks reduces irritation while improving efficacy 1

Important compatibility issues to avoid:

• Never apply salicylic acid simultaneously with calcipotriene - the acidic pH inactivates calcipotriene and eliminates its effectiveness 1, 4
• Apply different topical agents at separate times throughout the day to prevent inactivation 2

Common Pitfalls and How to Avoid Them

Duration limits for corticosteroids:

• Class I (superpotent) corticosteroids: maximum 2-4 weeks continuous use to prevent skin atrophy, striae, and systemic absorption 1, 2
• Gradual tapering after clinical response is recommended, though exact protocols vary 1
• Weekend-only application after initial treatment maintains efficacy while reducing adverse effects 1

Local adverse effects of corticosteroids:

• Skin atrophy, striae, folliculitis, telangiectasia, and purpura occur with prolonged use 2
• Use lower potency agents on face, intertriginous areas, and in children 2, 4

Calcineurin inhibitor considerations:

• Burning and itching are common initially but typically improve with continued use 2
• Preferred for facial/intertriginous areas due to lack of atrophy risk 2, 4

Tazarotene precautions:

• Contraindicated in pregnancy (Category X) - must discontinue if pregnancy recognized 1, 2
• Causes significant irritation when used alone; always combine with corticosteroids to reduce this effect 1

Additional Topical Options

For refractory or specific cases:

• Tazarotene 0.1% cream/gel for 8-12 weeks shows comparable efficacy to fluocinonide cream 1
• Coal tar preparations (0.5-10%) can be used as alternative therapy 4
• Anthralin for difficult cases refractory to conventional treatment 5, 7

Adjunctive therapy:

• Emollients should always be added to reduce itching, desquamation, and prevent quick relapse 4
• Salicylic acid can be combined with corticosteroids (but NOT calcipotriene) to increase absorption in thick plaques 5