What are the alternatives to Dovonex (calcipotriene) for a patient with psoriasis?

Alternatives to Dovonex (Calcipotriene) for Psoriasis

Topical corticosteroids are the primary alternative to Dovonex, with high-potency corticosteroids (Class I-III) recommended as first-line therapy for mild to moderate plaque psoriasis, showing efficacy rates of 58-92% in controlled trials. 1, 2

First-Line Alternatives

Topical Corticosteroids

• High-potency topical corticosteroids (Class I-III) should be used for up to 4 weeks for initial treatment of plaque psoriasis, with dosing 1-2 times daily based on disease location and severity 1, 2
• Ultra-high potency agents like clobetasol and halobetasol demonstrate superior efficacy compared to calcipotriene, with maximum weekly use limited to 50g or less to minimize systemic absorption 1
• For long-term management, weekend-only application of high-potency corticosteroids can maintain remission while reducing the risk of skin atrophy and tachyphylaxis 1, 3

Combination Therapy (Corticosteroid + Vitamin D Analogue)

• The combination of calcipotriene with betamethasone propionate/dipropionate is more effective than either agent alone, with 48% of patients achieving significant improvement in 4 weeks 1, 3
• This combination provides corticosteroid-sparing effects and reduces long-term adverse effects 3
• Available as ointment, gel, or foam formulations for different body sites 1, 4

Additional Topical Alternatives

Tazarotene

• Topical retinoid with Level I evidence (Grade A recommendation) for psoriasis treatment 1
• Can be combined with corticosteroids for enhanced efficacy 1

Calcineurin Inhibitors

• Tacrolimus 0.1% ointment is recommended for facial and intertriginous psoriasis for up to 8 weeks, where corticosteroid use carries higher risk of atrophy 2, 3
• Pimecrolimus 1% cream can be used for inverse psoriasis in sensitive areas for 4-8 weeks 3
• These agents have Level II evidence (Grade B recommendation) 1

Coal Tar Preparations

• Coal tar 15% solution demonstrated 58% mean reduction in PASI scores compared to 37% with calcipotriene in a 12-week trial 5
• Coal tar is a corticosteroid-sparing alternative with Grade B recommendation, though cosmetic acceptability varies 1, 5

Anthralin

• Traditional agent with Grade C recommendation based on Level III evidence 1
• Typically reserved for resistant plaques due to staining and irritation concerns 1

Site-Specific Alternatives

Scalp Psoriasis

• Topical corticosteroid solutions, foams, or shampoos for at least 4 weeks 2
• Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 2, 4

Facial and Intertriginous Areas

• Lower potency corticosteroids or tacrolimus 0.1% are preferred to minimize atrophy risk 2, 3
• Calcipotriene combined with hydrocortisone for 8 weeks is effective for facial psoriasis 3, 4

Treatment Algorithm for Moderate to Severe Disease

When topical therapy proves insufficient:

• Phototherapy (narrowband UVB) as second-line treatment 2
• Biologics (TNF-α, IL-17, IL-23 inhibitors) as first-line for moderate-to-severe disease, with infliximab dosed at 5 mg/kg at weeks 0,2,6, then every 8 weeks 2
• Traditional systemic agents (methotrexate, acitretin, cyclosporine) as alternatives 2

Critical Considerations

Avoiding Common Pitfalls

• Never use salicylic acid simultaneously with calcipotriene, as acidic pH inactivates the vitamin D analogue 3, 4
• Apply vitamin D analogues after phototherapy sessions, as UVA radiation decreases drug concentration on skin 3, 4
• Avoid prolonged continuous use of high-potency corticosteroids due to risks of skin atrophy, striae, telangiectasia, and HPA axis suppression 1, 2

Maintenance Strategy

• Transition from high-potency corticosteroids to less potent agents or intermittent dosing after initial clearance to minimize long-term adverse effects 1
• Weekend corticosteroid application combined with weekday vitamin D analogue use maintains remission in 76% of patients at 6 months 6