Mometasone Cream in Psoriatic Arthritis
Mometasone cream is appropriate only for treating the skin manifestations of psoriasis in patients with psoriatic arthritis, but it has no role in treating the joint disease itself and should never be used as monotherapy when active arthritis is present.
Role of Topical Corticosteroids in PsA
Mometasone furoate 0.1% is a potent topical corticosteroid that effectively treats psoriatic skin lesions when applied once daily, demonstrating superior efficacy compared to less potent agents like fluocinolone acetonide and equivalent results to triamcinolone acetonide 1, 2. However, topical corticosteroids address only the cutaneous component of psoriatic disease and provide no benefit for joint inflammation, structural damage prevention, or systemic disease control 3.
Treatment Priorities in Active PsA
When managing patients with psoriatic arthritis, the musculoskeletal manifestations must be addressed with systemic disease-modifying therapy, not topical agents 3. The primary treatment goal is maximizing health-related quality of life through control of symptoms, prevention of structural damage, normalization of function, and abrogation of inflammation 3, 4.
Systemic Therapy Requirements
For polyarthritis: Initiate a conventional synthetic DMARD (csDMARD) rapidly, with methotrexate strongly preferred when relevant skin involvement is present 3, 4
For inadequate csDMARD response: Commence biologic DMARD (bDMARD) therapy; when relevant skin involvement exists, IL-17 inhibitors or IL-12/23 inhibitors should be preferred over TNF inhibitors 3, 4
For bDMARD failure: Consider JAK inhibitors as targeted synthetic DMARDs 3, 4
Appropriate Use of Mometasone in PsA Context
Mometasone cream may be used as adjunctive therapy only for localized psoriatic skin lesions in patients already receiving appropriate systemic therapy for their joint disease 1, 2. This is particularly relevant when:
- Skin involvement is limited to specific areas requiring targeted treatment 1, 2
- The patient is on systemic therapy that adequately controls joint disease but has residual skin lesions 5, 6
- Once-daily application is preferred for adherence, as mometasone demonstrates efficacy with this regimen 1, 2
Critical Pitfalls to Avoid
Never delay systemic DMARD therapy in favor of topical treatments when active arthritis is present, as uncontrolled arthritis causes radiologic joint damage in 50% of patients 7. The European League Against Rheumatism explicitly recommends that treatment decisions must consider each musculoskeletal manifestation separately, and skin treatments alone are insufficient for PsA management 3.
Avoid systemic corticosteroids as primary therapy for psoriatic arthritis despite their use in other inflammatory arthritides, as they carry risk of disease deterioration after withdrawal 8. Local glucocorticoid injections may be considered as adjunctive therapy for specific joints, but systemic steroids should be used with caution at the lowest effective dose only 3.
Integrated Treatment Approach
When both skin and joint manifestations require treatment, prioritize systemic agents effective for both domains 5, 6. Methotrexate, TNF inhibitors (adalimumab, etanercept, infliximab, golimumab), IL-17 inhibitors (secukinumab), and IL-12/23 inhibitors (ustekinumab) all demonstrate efficacy for both psoriatic skin and joint disease 5, 6. Mometasone cream can supplement these systemic therapies for localized skin lesions but should never substitute for disease-modifying treatment 1, 2.
Monitoring and Adjustment
Treatment should aim for remission or low disease activity through regular disease activity assessment and appropriate therapy adjustment 3, 4. If skin lesions persist despite systemic therapy, adding or optimizing topical mometasone is reasonable, but inadequate joint disease control mandates escalation of systemic therapy, not increased reliance on topical agents 3, 4.