From the Guidelines
Topical treatments, specifically combination therapies with vitamin D analogues and potent topical corticosteroids, are the most effective first-line therapy for mild to moderate psoriasis, as they have been shown to improve symptoms and quality of life while minimizing adverse effects. The use of calcipotriene or tacalcitol ointment combined with hydrocortisone is efficacious for the treatment of facial psoriasis, as demonstrated in an 8-week double-blind RCT 1. For scalp psoriasis, calcipotriene foam has been shown to be more effective than vehicle in achieving an Investigator’s Static Global Assessment score of 0 or 1 1.
Key considerations for topical treatment include:
- Using lower potency corticosteroids on the face, intertriginous areas, and areas susceptible to steroid atrophy
- Applying a thin layer to affected areas 1-2 times daily for 2-4 weeks, then tapering to avoid rebound
- Rotating between different medication classes to prevent tachyphylaxis and minimize side effects
- Using moisturizers regularly to reduce dryness and enhance barrier function
- Considering combination products with calcipotriene and corticosteroids for optimal results, as supported by a 52-week study with 828 patients 1
The most recent and highest quality study, published in 2021, recommends the use of combination treatments with vitamin D analogues and potent topical corticosteroids for up to 52 weeks for the treatment of psoriasis, with a strength of recommendation of A 1. This study also notes that the application of vitamin D analogues twice daily on weekdays in conjunction with high-potency topical corticosteroids twice daily on weekends can be considered for maintenance treatment for psoriasis.
Overall, the goal of topical treatment for psoriasis is to reduce inflammation, normalize skin cell turnover, and decrease the hyperproliferation of keratinocytes that causes the characteristic plaques, while minimizing adverse effects and improving quality of life.
From the FDA Drug Label
Apply triamcinolone acetonide cream USP, 0. 1% as appropriate, to the affected area two to three times daily. Calcipotriene ointment, 0.005%, is indicated for the treatment of plaque psoriasis in adults.
Topical psoriasis treatments include:
From the Research
Topical Psoriasis Treatment Options
- Topical treatments combining corticosteroids and vitamin D analogues are well-established first-line treatments for mild-to-moderate psoriasis 4, 5, 6, 7
- The combination of potent and superpotent corticosteroids with vitamin D analogues provides an improvement of psoriasis within 2 weeks, reaching a maximal improvement after 4 weeks in the majority of patients 5
- Topical vitamin D analogs and corticosteroids act via distinct and complementary mechanisms of action, making their combination a biologically rational approach for the treatment of plaque psoriasis 6
Key Considerations for Topical Treatment
- The choice of topical treatment should take into account the severity of the disease, site of psoriasis, patient lifestyle and preferences, and intended duration of treatment 4, 7
- The combination of topical corticosteroids and vitamin D analogs has been shown to have a greater effect on the immune-mediated mechanisms of psoriasis than either monotherapy used alone 6
- Fixed combination therapy is recommended for maintenance therapy, once or twice a week 7
Special Considerations
- Topical therapy is the gold standard in mild psoriasis cases and is also recommended in addition to UV and systemic therapy in cases of moderate to severe psoriasis 7
- Special localizations, such as scalp, facial, intertriginous/genital, or palmoplantar lesions, require specific consideration when selecting a topical treatment 7
- Patient preferences and experiences should be taken into account to increase adherence to topical treatment 7