What is the best initial topical treatment for suspected psoriasis?

From the Guidelines

The best initial topical treatment for suspected psoriasis is a medium-potency topical corticosteroid such as triamcinolone 0.1% cream or ointment, applied twice daily to affected areas for 2-4 weeks. For facial or intertriginous areas (skin folds), lower potency options like hydrocortisone 1-2.5% are preferred to minimize side effects. Corticosteroids work by reducing inflammation, decreasing cell proliferation, and suppressing immune responses that drive psoriatic plaques.

Key Considerations

• The choice of vehicle can significantly alter the use and penetration of the medication and therefore alter the efficacy, as noted in 1.
• For maintenance after initial improvement, consider tapering to weekend-only application or transitioning to non-steroidal alternatives like calcipotriene (a vitamin D analog) or calcineurin inhibitors (tacrolimus, pimecrolimus), as suggested in 1.
• Combining a topical corticosteroid with calcipotriene can be more effective than either agent alone, as supported by the guidelines in 1.
• Moisturizers should be used regularly as adjunctive therapy to improve barrier function and reduce scaling.
• If there's no improvement after 2-4 weeks of appropriate treatment, reassess the diagnosis or consider referral to dermatology for more advanced therapies.

Treatment Approach

• Topical corticosteroids are the cornerstone of treatment for the majority of patients with psoriasis, particularly those with limited disease, as stated in 1 and 1.
• The efficacy of topical corticosteroids varies due to differences in study designs, patient populations, and end points, making it difficult to do an accurate statistical comparison of the majority of published studies, as discussed in 1.
• Ultrahigh-potency (class 1) corticosteroids may be required for areas with thick, chronic plaques, but their use should be balanced against the potential for side effects, as noted in 1.

From the FDA Drug Label

Tazarotene cream, 0.1% is a prescription medicine used on the skin (topical) to treat people with plaque psoriasis. Tazarotene cream, 0.1% is indicated for the topical treatment of patients with plaque psoriasis. The best initial topical treatment if suspecting psoriasis is tazarotene cream, 0.1% 2 2.

• Key points:
  • Tazarotene cream, 0.1% is used for the topical treatment of plaque psoriasis.
  • It is a prescription medicine.
  • Apply only to psoriasis skin lesions, avoiding uninvolved skin.

From the Research

Initial Topical Treatment for Suspected Psoriasis

• The best initial topical treatment for suspected psoriasis involves the use of corticosteroids, vitamin D analogues, topical retinoids, and calcineurin inhibitors 3.
• A combination of potent and superpotent corticosteroids with vitamin D analogues has been shown to provide an improvement in psoriasis within 2 weeks, reaching a maximal improvement after 4 weeks in the majority of patients 3.
• The combination of corticosteroids with tazarotene or with calcineurin inhibitors does not provide an advantage above corticosteroid monotherapy 3.
• A weekday/weekend treatment regimen involving calcitriol ointment and clobetasol propionate spray has been shown to be effective and well-tolerated for the treatment of moderate plaque psoriasis 4.

Topical Therapies for Psoriasis

• Topical treatments for psoriasis include corticosteroids, vitamin D derivatives, tazarotene, anthralin, tacrolimus, pimecrolimus, and newer formulations of tar 5.
• The choice of vehicle and patient adherence to medication are key factors for a treatment to be effective 5.
• Addressing patient preferences about treatments and concerns about treatment-related toxicities and managing their expectations represent additional aspects of patient care 5.

Efficacy of Topical Corticosteroids

• Topical corticosteroids have been used for over 50 years to treat mild-to-moderate plaque psoriasis 6.
• The efficacy of topical corticosteroids varies across studies, with 30-90% of patients experiencing more than 50% improvement of initial psoriasis severity 6.
• Maintenance intermittent treatment with topical corticosteroids appears to be useful to prolong remission 6.