What topical cream is recommended for treating psoriasis?

Topical Corticosteroids as First-Line Treatment for Psoriasis

For localized plaque psoriasis, start with a moderate to high-potency topical corticosteroid (Class 2-5) applied twice daily for 2-4 weeks, with Class 1 (ultra-high potency) corticosteroids like clobetasol propionate 0.05% reserved for thick, chronic plaques on the trunk and extremities. 1

Initial Treatment Selection by Disease Severity and Location

For Body/Trunk/Extremity Psoriasis:

• Class 1 (ultra-high potency) corticosteroids such as clobetasol propionate 0.05% or halobetasol propionate achieve 58-92% efficacy rates for moderate to severe plaque psoriasis 1
• Clobetasol propionate foam 0.05% demonstrates 68% of patients achieving clear or almost clear skin after 2 weeks of twice-daily application, compared to 21% with placebo 2
• Class 2-5 (moderate to high potency) corticosteroids are recommended as initial therapy for adults with mild to moderate disease 1
• Apply twice daily for 2-4 weeks as initial treatment 1, 3

For Facial and Intertriginous Areas:

• Use only low-potency corticosteroids (Class 6-7) on the face, intertriginous areas, and areas susceptible to atrophy like forearms 1
• Alternatively, use topical calcineurin inhibitors (tacrolimus 0.1% ointment or pimecrolimus 0.1% cream) as first-line treatment for these sensitive areas, with 65-71% efficacy rates 3

For Scalp Psoriasis:

• Class 1-7 topical corticosteroids are recommended for initial and maintenance treatment for a minimum of up to 4 weeks (Strength of Recommendation A, Level of Evidence I) 1, 4
• Vehicle formulations specifically designed for scalp application (solutions, foams, shampoos) improve adherence and efficacy compared to creams or ointments 4

Combination Therapy for Enhanced Efficacy

Combining calcipotriene (vitamin D analogue) with betamethasone dipropionate is more effective than either agent alone and should be considered for maintenance therapy. 1, 4

• The fixed combination of calcipotriene 0.005% plus betamethasone dipropionate 0.064% achieves 69-74% clear or almost clear status in long-term use (up to 52 weeks) 1, 4
• This combination can be used safely for up to 52 weeks without serious adverse events including striae or hypothalamic-pituitary-adrenal axis suppression 1, 4
• For maintenance, apply high-potency topical corticosteroids twice daily on weekends with vitamin D analogues twice daily on weekdays 1
• Alternatively, apply morning high-potency topical corticosteroids and evening topical vitamin D analogues 1

Alternative Topical Agents

Tazarotene (Topical Retinoid):

• Tazarotene 0.1% cream is FDA-approved for plaque psoriasis and demonstrates 46% median reduction in lesions after 12 weeks 5
• Tazarotene is Pregnancy Category X and absolutely contraindicated in women of childbearing potential without effective contraception 5
• Apply once daily in the evening to psoriasis lesions only, avoiding uninvolved skin 5

Vitamin D Analogues (Monotherapy):

• Long-term use of topical vitamin D analogues (calcipotriene, calcitriol, tacalcitol) for up to 52 weeks is recommended for mild to moderate psoriasis (Strength of Recommendation A) 1
• Calcipotriene foam achieves 40.9% clear or almost clear status after 8 weeks for scalp psoriasis 4
• Avoid simultaneous use of salicylic acid with calcipotriene as the acid pH will inactivate calcipotriene 1, 3

Treatment Duration and Monitoring

• Initial treatment with Class 1-5 corticosteroids should be limited to up to 4 weeks (Strength of Recommendation A, Level of Evidence I) 1
• Long-term use beyond 12 weeks can be considered only under careful physician supervision (Strength of Recommendation C, Level of Evidence III) 1
• Gradually reduce frequency after clinical improvement to prevent rebound 4
• For localized non-responding or very thick lesions, intralesional triamcinolone acetonide up to 20 mg/mL can be used every 3-4 weeks 1

Critical Safety Considerations

Common Adverse Effects:

• Most common local adverse effects include skin atrophy, striae, folliculitis, telangiectasia, and purpura 1, 3
• Face and intertriginous areas are at greatest risk for these adverse effects 1
• Burning and stinging sensations are common with initial application but typically improve with continued use 3

Important Precautions:

• Match corticosteroid potency to disease severity, body location, and treatment duration 3
• Use moisturizers/emollients frequently to reduce itching and desquamation 3
• Avoid excessive sun exposure and use sunscreens, especially with tazarotene 5
• For women of childbearing potential, most topical psoriasis medications are pregnancy category C, except tazarotene which is category X 4, 5