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% or mometasone 0.1% cream or ointment, applied twice daily to affected areas for 2-4 weeks, as recommended by the joint AAD-NPF guidelines of care for the management and treatment of psoriasis with topical therapy 1.

Key Considerations

• Ointments are generally more effective than creams for the thick plaques of psoriasis as they provide better penetration and occlusion.
• For facial or intertriginous areas (skin folds), lower potency steroids like hydrocortisone 1-2.5% should be used to minimize side effects.
• Vitamin D analogs like calcipotriene (Dovonex) 0.005% ointment or calcitriol (Vectical) 0.003% ointment are excellent steroid-sparing agents that can be used alone or in combination with steroids.

Combination Therapies

• The combination product calcipotriene/betamethasone dipropionate (Enstilar foam or Taclonex ointment) is particularly effective and can be applied once daily, as supported by a 52-week study with 828 patients 1.
• Combining separate vitamin D and corticosteroid preparations into specific easy-to-follow regimens can be used to reduce both the adverse effects of topical corticosteroids and the cost for some patients.

Application and Maintenance

• Patients should be advised to apply treatments after bathing when skin is hydrated, and to use emollients regularly to maintain skin barrier function and enhance treatment efficacy.
• Topical steroids work by reducing inflammation and suppressing immune responses in the skin, while vitamin D analogs normalize keratinocyte differentiation and proliferation, addressing the rapid skin cell turnover characteristic of psoriasis.

From the FDA Drug Label

Calcipotriene ointment, 0.005%, is indicated for the treatment of plaque psoriasis in adults. The best initial topical treatment if suspecting psoriasis is calcipotriene (TOP), as it is directly indicated for the treatment of plaque psoriasis in adults 2.

From the Research

Topical Treatment Options for Psoriasis

• Topical vitamin D analogs (e.g., calcipotriene) and corticosteroids (e.g., betamethasone) are the most widely prescribed psoriasis drugs and are the cornerstone of topical therapies 3.
• The combination of corticosteroids with vitamin D analogs has been shown to be effective in the treatment of psoriasis, with the fixed-dose combination of betamethasone and calcipotriol being more effective than either drug alone 4, 5.
• Topical corticosteroids are also effective in the treatment of psoriasis, with maintenance intermittent treatment shown to prolong remission 6.

Initial Topical Treatment for Suspected Psoriasis

• The best initial topical treatment for suspected psoriasis is likely to be a combination of a topical corticosteroid and a vitamin D analog, such as the fixed-dose combination of betamethasone and calcipotriol 4, 5.
• Alternatively, a topical corticosteroid alone, such as betamethasone, may be used as an initial treatment, with the option to add a vitamin D analog later if necessary 6.
• Vitamin D analogs, such as calcipotriene, may also be used as an initial treatment, either alone or in combination with a corticosteroid 3, 7.

Considerations for Treatment

• The choice of treatment should be individualized for each patient, taking into account the severity of the disease, the location of the lesions, and the patient's preferences and lifestyle 4, 5.
• Patients should be proactively involved in the choice of treatment, formulation, and mode of application 5.
• Standardized and simplified treatment application modes may result in better clinical outcomes compared to on-demand therapies 5.