What is the first line treatment for facial psoriasis?

First-Line Treatment for Facial Psoriasis

For facial psoriasis, use calcipotriene (or tacalcitol) combined with hydrocortisone as first-line therapy, applied for 8 weeks. 1

Recommended Treatment Regimen

The combination of a vitamin D analogue with a low-potency corticosteroid is specifically more effective on the face than either agent alone. 1 An 8-week RCT demonstrated that calcipotriene combined with hydrocortisone achieved significantly better facial clearance (Investigator Global Assessment score of 0 or 1) compared to calcipotriene alone, with an odds ratio of 2.01 (95% CI: 1.33-3.05, P = .001). 1

Application Strategy

• Apply calcipotriene combined with hydrocortisone twice daily for the initial 2 weeks 1
• After initial control, transition to weekend-only hydrocortisone application with weekday calcipotriene to minimize corticosteroid exposure while maintaining efficacy 1
• Limit total vitamin D analogue use to maximum 100 g per week to avoid hypercalcemia 1

Alternative First-Line Option for Sensitive Facial Skin

Tacrolimus 0.1% ointment can be used as monotherapy for facial psoriasis, particularly when corticosteroid-related atrophy is a concern. 1 This is an off-label use but specifically recommended by the AAD-NPF guidelines for facial and genital psoriasis. 1

• Tacrolimus avoids the risk of skin atrophy that occurs with corticosteroids on thin facial skin 1
• Case series demonstrate clearance within 2 weeks in pediatric facial psoriasis, with similar efficacy expected in adults 1
• The main limitation is initial burning/stinging at application sites 1

Why Calcitriol May Be Preferred Over Calcipotriene

Calcitriol ointment is less irritating than calcipotriene and better tolerated on sensitive facial skin. 1 Since facial skin is more prone to irritation, calcitriol represents an excellent alternative vitamin D analogue when combined with hydrocortisone for facial psoriasis. 1

Critical Pitfalls to Avoid

• Never use high-potency (Class 1-2) corticosteroids on the face due to significantly increased risk of skin atrophy, telangiectasias, and perioral dermatitis in this thin-skinned area 1
• Do not combine calcipotriene with salicylic acid, as the acidic pH inactivates calcipotriene and eliminates its effectiveness 1, 2
• Avoid abrupt discontinuation of corticosteroids without transitioning to maintenance therapy, as this causes severe rebound flares 1, 2
• Do not use potent betamethasone dipropionate combinations on the face, as these are appropriate for body/scalp psoriasis but too strong for facial application 1

When This Approach Fails

If facial psoriasis does not respond adequately after 8 weeks of topical therapy, consider escalation to phototherapy or systemic agents rather than increasing corticosteroid potency on the face. 1, 2