Treatment of Facial Psoriasis
Start with calcipotriene (vitamin D analogue) combined with a low-potency corticosteroid applied twice daily for 8 weeks as first-line therapy for facial psoriasis. 1, 2
First-Line Treatment Protocol
Combination therapy with calcipotriene plus low-potency corticosteroid (such as hydrocortisone) is the recommended initial approach, demonstrating significantly superior clearance compared to monotherapy (odds ratio 2.01,95% CI: 1.33-3.05). 1, 2
Application Strategy:
- Apply the combination twice daily for the first 2 weeks 2
- After initial 2 weeks, transition to weekend-only corticosteroid application with weekday calcipotriene monotherapy to minimize corticosteroid exposure while maintaining efficacy 2
- Continue treatment for total duration of 8 weeks 1, 2
- Limit total vitamin D analogue use to maximum 100 g per week to avoid hypercalcemia 2
Alternative First-Line Option
Tacrolimus 0.1% ointment is the preferred alternative when corticosteroid-related side effects are a concern, particularly for sensitive facial skin. 1, 2
- Achieves clearance within 2 weeks in pediatric facial psoriasis 1, 2
- Avoids the risk of skin atrophy, telangiectasias, and perioral dermatitis that occurs with corticosteroids on thin facial skin 1, 2, 3
- This calcineurin inhibitor has level 1 evidence for efficacy in facial psoriasis 3
Critical Contraindications for Facial Psoriasis
Never use high-potency (Class 1-2) or moderately potent (Class 3) corticosteroids on facial skin due to significantly increased risk of skin atrophy, telangiectasias, and perioral dermatitis. 1, 2, 3
Avoid anthralin (dithranol) on the face as it causes severe irritation and staining on sensitive facial sites. 4, 3
Do not combine calcipotriene with salicylic acid as the acidic pH inactivates calcipotriene and eliminates its therapeutic effectiveness. 1, 2
Adjunctive Therapy
Add emollients in conjunction with topical corticosteroids for 4 to 8 weeks to help reduce itching, desquamation, and prevent quick relapse when topical corticosteroids are discontinued. 4
When to Escalate Treatment
If first-line topical treatments fail after an adequate 8-week trial, escalation to phototherapy (UVB or narrowband UVB) or systemic therapy is indicated. 1
Facial psoriasis is classified as a "vulnerable area" that warrants consideration for systemic therapy even with limited body surface area involvement if there is more than minimal impact on quality of life or inadequate response to localized therapy. 4
The decision to escalate to systemic treatment should be made by a dermatologist experienced in managing psoriasis, considering both objective disease severity and psychosocial impact. 4, 1
Important Clinical Context
Facial psoriasis occurs in 17-46% of psoriatic patients and serves as a prognostic marker indicating a poor prognosis of psoriasis overall. 3 The face requires special caution due to thin skin that is more susceptible to corticosteroid-induced atrophy and other adverse effects. 3