Treatment of Mild to Moderate Psoriasis
For mild to moderate psoriasis, use a fixed-combination product of calcipotriene/betamethasone dipropionate applied once daily for 4-12 weeks as first-line therapy. 1
First-Line Topical Therapy
The combination of a vitamin D analogue (calcipotriene) with a mid- to high-potency topical corticosteroid provides superior efficacy compared to either agent alone and represents the standard of care. 2
Key treatment approach:
Apply calcipotriene/betamethasone dipropionate fixed-combination product once daily for 4-12 weeks, which achieves 69-74% clear or almost clear status compared to 27% with vehicle control. 2, 3
For maintenance therapy after initial treatment, use vitamin D analogues twice daily on weekdays combined with high-potency topical corticosteroids twice daily on weekends. 2
Alternative maintenance regimen: Apply high-potency topical corticosteroid in the morning and vitamin D analogue in the evening. 2, 1
Long-term use of vitamin D analogues is safe for up to 52 weeks without serious adverse events including striae or hypothalamic-pituitary-adrenal axis suppression. 2
Essential Precautions to Avoid Treatment Failure
Never combine calcipotriene with salicylic acid - the acidic pH completely inactivates calcipotriene and eliminates its effectiveness. 2, 1
Apply calcipotriene after phototherapy sessions, not before - UVA radiation decreases calcipotriene concentration on the skin, and thick layers of calcipotriene can block UVB radiation. 2, 1
Site-Specific Treatment Modifications
For scalp psoriasis:
For facial or flexural psoriasis:
- Use calcipotriene combined with hydrocortisone (low-potency corticosteroid) for 8 weeks, or tacalcitol ointment for 8 weeks. 2, 1
- Avoid ultrapotent corticosteroids on the face due to risk of atrophy and other adverse effects. 3
For nail psoriasis:
- Apply calcipotriene/betamethasone dipropionate to reduce nail thickness, hyperkeratosis, and onycholysis. 1, 4
Alternative Topical Retinoid Option
If adding tazarotene (0.05-0.1% gel or cream), always combine it with a mid- to high-potency topical corticosteroid applied for 8-16 weeks. 2, 1
- The combination of tazarotene with corticosteroid is more effective than tazarotene monotherapy and reduces local irritation. 2, 5
- This combination increases duration of treatment effect and time to remission. 2
- Tazarotene is absolutely contraindicated in pregnancy - obtain negative pregnancy test 2 weeks before starting in women of childbearing age. 2, 1
Adjunctive Emollient Therapy
Apply emollients in conjunction with topical corticosteroids for 4-8 weeks to reduce itching, scaling, and body surface area involvement. 1
- Apply emollients after calcipotriene/corticosteroid combination to avoid washing off active medication. 1
- Emollients are safe during pregnancy and lactation with minimal risk of contact dermatitis unless hypersensitivity to ingredients exists. 1
When to Escalate Beyond Topical Therapy
Contact a physician if body surface area involvement exceeds 10% (approximately the size of 10 palms), as this indicates moderate to severe disease requiring systemic therapy consideration. 1