What is the recommended first‑line topical therapy for mild‑to‑moderate plaque psoriasis?

Topical Psoriasis Treatment for Mild-to-Moderate Plaque Psoriasis

For mild-to-moderate plaque psoriasis, start with a combination product containing calcipotriene and betamethasone dipropionate applied once daily for up to 52 weeks as first-line therapy. 1

Primary Treatment Approach

The calcipotriene/betamethasone dipropionate combination is recommended as first-line treatment with Grade A evidence, providing synergistic efficacy while reducing corticosteroid-related adverse effects compared to corticosteroid monotherapy. 1 This combination is available as gel, ointment, or foam formulations. 1

Why Combination Therapy First?

• The combination of calcipotriene with potent betamethasone dipropionate is slightly more efficacious than betamethasone monotherapy. 2
• In a 52-week study of 828 patients, 69-74% achieved clear or almost clear status with calcipotriene 0.005% plus betamethasone 0.064% once or twice daily, compared to only 27% with vehicle control (P < 0.001). 2
• No serious adverse events, including striae or hypothalamic-pituitary-adrenal axis suppression, were observed over the 52-week treatment period. 2
• Use of combination products with calcipotriol and corticosteroids is recommended for the treatment of psoriasis with Grade A strength of recommendation. 2

Alternative Sequential Regimen

If combination products are unavailable or not preferred, use this evidence-based sequential approach:

Weeks 1-4: High-Potency Corticosteroid Induction Phase

• Apply class 2-5 (moderate to high potency) topical corticosteroids once or twice daily for 2-4 weeks as initial therapy. 2
• For thick, chronic plaques, use class 1 (ultrahigh-potency) corticosteroids like clobetasol propionate or halobetasol propionate. 2
• Efficacy rates range from 58-92% with ultrahigh-potency corticosteroids. 2
• In one trial, halobetasol propionate ointment improved Physician's Global Assessment scores by 92% compared with 39% in vehicle-treated patients after 2 weeks (P < 0.0003). 2

Weeks 5-52: Vitamin D Analogue Maintenance Phase

• After initial corticosteroid response, transition to calcipotriene (vitamin D analogue) applied twice daily for long-term maintenance up to 52 weeks. 2, 1
• Long-term use of topical vitamin D analogues (up to 52 weeks) is recommended for the treatment of mild to moderate psoriasis with Grade A strength of recommendation. 2
• This transition prevents tachyphylaxis and minimizes corticosteroid-related adverse effects including skin atrophy, striae, and telangiectasia. 2

Alternative Maintenance Regimens

Weekday/Weekend Split Regimen

• Apply vitamin D analogues twice daily on weekdays in conjunction with high-potency topical corticosteroids twice daily on weekends for maintenance treatment (Grade B recommendation). 2
• This regimen is effective and well-tolerated for moderate plaque psoriasis. 3

Morning/Evening Split Regimen

• Apply high-potency topical corticosteroid in the morning and vitamin D analogue in the evening (Grade B recommendation). 2
• This reduces adverse effects while maintaining efficacy. 4

Site-Specific Modifications

Scalp Psoriasis

• Use calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks (Grade A recommendation). 2, 1
• Class 1-7 topical corticosteroids for a minimum of up to 4 weeks are recommended as initial and maintenance treatment. 2

Face and Intertriginous Areas

• Use lower potency corticosteroids (class 6-7) to minimize atrophy risk. 2
• Tacalcitol ointment or calcipotriene combined with hydrocortisone for 8 weeks can be used (Grade B recommendation). 2, 1
• These areas are at greatest risk for developing adverse effects including skin atrophy, striae, folliculitis, and telangiectasia. 2

Thick Plaques on Body

• Use class 1 ultrahigh-potency corticosteroids for areas with thick, chronic plaques. 2
• After 2-4 weeks, transition to maintenance therapy with vitamin D analogues. 1

Critical Pitfalls to Avoid

• Never use salicylic acid simultaneously with calcipotriene, as the acidic pH inactivates calcipotriene and reduces effectiveness. 2, 1, 5
• Do not use Class 1 corticosteroids continuously beyond 2-4 weeks due to risk of HPA axis suppression, skin atrophy, striae, and telangiectasia. 1
• Avoid applying vitamin D analogues before phototherapy, as thick layers can block UVB radiation; apply after phototherapy treatment to avoid inactivation by UVA. 2
• Do not use high-potency corticosteroids on face, intertriginous areas, or forearms without careful monitoring, as these areas are susceptible to steroid atrophy. 2

Adjunctive Therapy

• Add nonmedicated moisturizers applied 1-3 times daily to reduce itching, scaling, and desquamation. 2, 1
• Moisturizers can be used as part of a general treatment regimen for all patients with psoriasis. 2

When to Consider Alternative Therapies

If inadequate response after 4-8 weeks of optimized topical therapy:

• Consider adding tazarotene 0.1% cream once daily for 8-12 weeks, which achieves 40-51% treatment success rates. 2, 1
• Combination of tazarotene with medium- or high-potency topical corticosteroid increases efficacy while reducing local adverse events. 2
• For disease involving >3-10% body surface area with inadequate topical response, consider narrowband UVB phototherapy or systemic therapy. 4