What topical ointments are recommended for treating psoriasis, considering the patient's medical history and potential allergies?

Topical Treatment for Psoriasis

First-Line Recommendation

For plaque psoriasis, start with a combination of a high-potency topical corticosteroid (Class 2-5) and calcipotriene (vitamin D analog) for up to 4 weeks, adjusting potency based on anatomical location. 1, 2

Treatment Algorithm by Body Location

Thick-Plaque Areas (Elbows, Knees)

• Use ultra-high potency (Class 1) corticosteroids such as clobetasol propionate 0.05% or halobetasol propionate 0.05% for up to 4 weeks maximum. 1
• These agents achieve 58-92% improvement in Physician's Global Assessment scores after 2 weeks, with halobetasol ointment showing 92% improvement versus 39% with vehicle (P < 0.0003). 1
• The elbow is not susceptible to steroid atrophy, making ultra-high potency appropriate, but do not extend application to the forearm which is susceptible. 1
• After clinical improvement, taper gradually: once daily → alternate days → twice weekly. 1

Scalp

• Use topical corticosteroids Class 1-7 for at least 4 weeks. 2
• Clobetasol propionate 0.05% spray produces significantly greater improvement in quality of life compared with vehicle using the Scalpdex instrument. 3

Face, Genitalia, and Intertriginous Areas

• Use low-potency corticosteroids or topical calcineurin inhibitors (tacrolimus 0.1%) to avoid skin atrophy. 2
• Calcineurin inhibitors are specifically recommended for these areas as they don't cause skin atrophy. 2

General Body Plaques (Non-Intertriginous)

• Use moderate to high potency corticosteroids (Class 2-5) for maximum 4 weeks. 2

Combination Therapy Strategy

Dual Therapy Regimen

• Combine high/ultra-high potency topical steroid with topical vitamin D analog (calcipotriene) either as separate products or as a fixed combination product. 2
• This provides synergistic effect and is more effective than either agent alone. 2
• Apply calcipotriene ointment 0.005% once or twice daily as a thin layer. 4

Maintenance Regimen

• For long-term management, use weekend-only application of corticosteroids while applying vitamin D analogs on weekdays. 2
• A weekday/weekend regimen with calcitriol ointment on weekdays and clobetasol propionate spray on weekends for 4 weeks is effective and well-tolerated. 5

Alternative First-Line Options

Coal Tar

• Start with 0.5-1.0% crude coal tar in petroleum jelly, increasing to maximum of 10%. 1, 2

Tazarotene (Topical Retinoid)

• Combine with moderate to high potency topical corticosteroids to reduce irritation while enhancing efficacy. 2
• Contraindicated in pregnancy; females of reproductive potential must use effective contraception. 2

Critical Safety Considerations

Duration Limits

• Do not continue clobetasol propionate beyond 4 weeks of continuous daily use due to significantly increased risk of cutaneous side effects and systemic absorption. 1
• Do not exceed 100g of moderate potency preparation per month. 2
• Plan annual periods where an alternative treatment is used. 2

Drug Interactions to Avoid

• Never use salicylic acid simultaneously with calcipotriene, as the acidic pH will inactivate calcipotriene and reduce effectiveness. 2
• Never use systemic corticosteroids as monotherapy, as they can precipitate pustular or erythrodermic psoriasis during or after taper. 2

Medications That Worsen Psoriasis

• Avoid beta-blockers and NSAIDs in some patients. 2
• Avoid lithium, chloroquine, and mepacrine due to risk of severe, potentially fatal psoriasis deterioration. 2

Vehicle Selection for Adherence

While ointments are traditionally considered most potent, patient preference for vehicle (spray, foam, lotion, cream) is more important for adherence than small differences in drug delivery. 6, 7

• Clobetasol propionate 0.05% spray produces significantly greater improvements in quality of life and similar efficacy to foam formulations. 3
• Efficacy rates are similar across vehicles (17-80%) when patients are compliant. 7
• Foam and spray formulations exceed 90% compliance and offer acceptable cosmetic characteristics. 8

When to Escalate Beyond Topicals

• Consider systemic therapy if moderate-to-severe involvement (>5% body surface area) persists despite optimized topical therapy. 1, 2
• Consider systemic therapy if there is significant impact on quality of life despite localized disease. 1