From the Guidelines
For a patient experiencing a psoriasis flareup while already using betamethasone 0.05% three times weekly, I recommend adding a vitamin D analog like calcipotriene once daily on alternating days with betamethasone, as this combination has been shown to be more effective than either agent alone 1. This approach is supported by a 52-week study with 828 patients, where 69% to 74% of patients treated with the combination of calcipotriene 0.005% and betamethasone 0.064% once or twice daily achieved clear or almost clear status compared to 27% of the patients in the placebo group 1. The patient should also incorporate daily moisturizing with fragrance-free emollients applied immediately after bathing to improve barrier function. For more extensive flares, consider adding narrowband UVB phototherapy 2-3 times weekly for 6-8 weeks. Trigger identification and management is crucial - patients should track potential triggers like stress, infections, or medication changes that may have precipitated the flare. This combination approach targets multiple pathways of psoriasis pathophysiology: steroids reduce inflammation, vitamin D analogs normalize keratinocyte differentiation, moisturizers repair barrier function, and phototherapy modulates immune responses. Some key points to consider when using topical corticosteroids include the choice of vehicle, which can significantly alter the use and penetration of the medication, and the potential for cutaneous side effects and systemic absorption with prolonged use 1. If improvement isn't seen within 2-3 weeks, the patient should return for reevaluation as they may require systemic therapy. It's also important to note that the efficacy of vitamin D analogues may take 8 weeks to become apparent, so patience and consistent treatment are essential 1. Overall, the goal is to find a balance between efficacy and safety, minimizing the risk of adverse effects while maximizing the benefits of treatment.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION: Apply a thin film of Betamethasone Valerate Cream or Ointment to the affected skin areas one to three times a day. Dosage once or twice a day is often effective. The recommended treatment for a patient with a psoriasis flareup who is already taking betamethasone 0.05% three times a week is to increase the frequency of application to one to three times a day, as needed, to control the flareup 2.
- The patient's current dosage of three times a week may not be sufficient to manage the flareup.
- Increasing the frequency of application to once or twice a day may be effective in managing the flareup.
- The dosage may be increased in stubborn cases, but it is essential to monitor the patient's response to the treatment and adjust the dosage accordingly.
From the Research
Treatment Options for Psoriasis Flareup
The patient is already taking betamethasone 0.05% three times a week. Considering this, the following options can be explored:
- Increasing the frequency of betamethasone application, but this should be done with caution to avoid potential side effects such as adrenal suppression 3.
- Combining betamethasone with other topical treatments, such as vitamin D analogs, to enhance its effectiveness 4, 5.
- Adding systemic treatments, such as methotrexate, to the existing topical treatment regimen. A study found that combining methotrexate with betamethasone orally weekly cleared lesions faster and with a longer remission period compared to methotrexate alone 6.
- Considering alternative topical corticosteroids, such as clobetasol propionate, which has been shown to be more effective than betamethasone valerate in a 6-month controlled study 7.
Key Considerations
When exploring these options, it's essential to consider the patient's individual needs, preferences, and potential concerns about treatment-related toxicities. Addressing these factors can improve patient adherence to the treatment regimen and ultimately lead to better outcomes 5.