What are the topical treatment options for plaque psoriasis?

From the Guidelines

Topical treatments are the first-line therapy for mild to moderate plaque psoriasis, and I recommend starting with a potent topical corticosteroid such as betamethasone dipropionate 0.05% or clobetasol propionate 0.05% cream applied once or twice daily to affected areas for 2-4 weeks, as supported by the most recent guidelines 1.

Key Considerations

• The choice of vehicle can significantly alter the use and penetration of the medication, and therefore alter the efficacy, with different vehicles indicated for different body sites 1.
• Occlusion of topical medications can also alter the penetration, thereby varying the effectiveness, as seen with flurandrenolide 0.1% functioning as a class 1 topical steroid when used as a tape 1.
• Vitamin D analogs such as calcipotriene 0.005% ointment are excellent steroid-sparing agents that can be used alone or in combination with steroids, and are recommended for long-term use up to 52 weeks for the treatment of mild to moderate psoriasis 1.

Treatment Strategies

• For maintenance therapy after initial improvement, consider transitioning to a medium-potency steroid or using the potent steroid only on weekends to minimize side effects.
• For facial or intertriginous areas, use lower potency steroids like hydrocortisone 1-2.5% to avoid skin atrophy.
• For scalp psoriasis, solutions, foams, or shampoos containing corticosteroids or calcipotriene are more appropriate than creams or ointments.
• Topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) are useful alternatives for sensitive areas.

Monitoring and Referral

• If topical therapy fails after 8-12 weeks of consistent use, consider referral for phototherapy or systemic treatments.
• Regular monitoring of patients with psoriasis is essential to assess treatment response and adjust therapy as needed, with consideration of patient preferences and goals 1.

From the FDA Drug Label

Tazarotene cream, 0.1% is indicated for the topical treatment of patients with plaque psoriasis. Apply a thin film (2 mg/cm 2) of tazarotene cream 0. 1% once per day, in the evening, to cover only the psoriatic lesions. Calcipotriene ointment, 0.005%, is indicated for the treatment of plaque psoriasis in adults.

Topical treatment options for plaque psoriasis include:

• Tazarotene cream, 0.1%: apply a thin film once per day, in the evening, to cover only the psoriatic lesions 2
• Calcipotriene ointment, 0.005%: for the treatment of plaque psoriasis in adults 3

From the Research

Topical Treatment Options for Plaque Psoriasis

• Topical corticosteroids, such as clobetasol propionate, offer effective and rapid healing of psoriatic lesions, but their long-term use is limited due to the risk of side effects 4.
• Calcipotriol is a safe option for long-term treatment, but its initial efficacy is lower than that of topical corticosteroids 4.
• A combination of clobetasol propionate followed by calcipotriol has been shown to be superior to calcipotriol alone in the treatment of plaque psoriasis 4.

Combination Therapies

• The combination of potent and superpotent corticosteroids with vitamin D analogues, such as calcipotriol, provides an improvement in psoriasis within 2 weeks, reaching a maximal improvement after 4 weeks in the majority of patients 5.
• Combinations of corticosteroids with tazarotene or calcineurin inhibitors do not provide an advantage above corticosteroid monotherapy 5.
• The combination of potent corticosteroids with calcipotriol is an efficacious and safe treatment option, with two-compound products being a practical solution 5.

Efficacy and Safety of Topical Therapies

• Corticosteroids are highly effective in psoriasis when used continuously for up to 8 weeks and intermittently for up to 52 weeks 6.
• Coal tar and retinoids are of limited benefit in the treatment of plaque psoriasis 6.
• There is a lack of long-term efficacy and safety data available on topical interventions used for psoriasis 6.

Alternative Treatment Regimens

• Calcitriol ointment has been shown to be a safe and effective alternative to calcipotriol ointment in the treatment of mild to moderate plaque psoriasis, when used in a regimen based on bitherapy with corticosteroids followed by vitamin D3 maintenance monotherapy 7.
• A new formulation of clobetasol propionate 0.025% cream has been developed, which incorporates half the concentration of traditional clobetasol propionate without losing its super-potency status 8.