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- Corticosteroids: Topical corticosteroids are the mainstay of treatment in mild or limited psoriasis and come in a variety of forms. Foams and solutions are best for scalp psoriasis and other thickly hair-bearing areas, such as a hairy chest or hairy back. Creams are usually preferred by patients, but ointments are more potent than any other vehicles, even at the same percentage concentration. Super potent topical corticosteroids such as clobetasol propionate (Temovate) and betamethasone dipropionate augmented (Diprolene) are commonly prescribed corticosteroids for use on non-facial, non-intertriginous areas (areas where skin surfaces do not rub together). As the condition improves, one may be able to use potent steroids such as mometasone furoate (Elocon) or halcinonide (Halog) or mid-potency steroids such as triamcinolone acetonide (Aristocort, Kenalog) or betamethasone valerate (Luxiq). These creams or ointments are usually applied once or twice a day, but the dose depends on the severity of the psoriasis as well as the location and thickness of the plaque. While it is best to use stronger, super potent corticosteroids on thicker plaques, milder steroids are recommended for skin folds (inverse psoriasis) and on the genitals. In skin folds or facial areas, it is best to use milder topical steroids such as hydrocortisone, desonide (DesOwen), or alclometasone (Aclovate).
- Drugs known as calcineurin inhibitors such as tacrolimus (Protopic) and pimecrolimus (Elidel) have less use in plaque type psoriasis than they do with eczema but are sometimes effective on the face or occluded areas. Patients who are using one or more of the systemic agents discussed below will often still require some use of topical corticosteroids for resistant areas and "hot spots." Occasionally, when there is concern about the long-term use of a potent topical corticosteroid, pulse methods may be used with one of the vitamin D or A analogs discussed below. An example would be to use the nonsteroidal topical agent (or a milder corticosteroid) during the week and more potent steroid on the weekends.
- Vitamin D: Calcipotriene (Dovonex) is a form of vitamin D3 and slows the production of excess skin cells. It is used in the treatment of moderate psoriasis. This cream, ointment, or solution is applied to the skin twice daily. Calcipotriene combined with the betamethasone dipropionate (Taclonex) flattens lesions, removes scale, and reduces inflammation and is available as an ointment and a solution. As is the case with many combination medications, it may be much less expensive to apply the individual components sequentially than a single application of a prepackaged mixture. Calcitriol ointment (Silkis, Vectical) contains calcitriol, which binds to the vitamin D receptors on skin cells and reduces the excessive production of skin cells, which helps to improve psoriasis. Calcitriol ointment should be applied to the affected areas of skin twice a day.
- Coal tar: Coal tar (DHS Tar, Doak Tar, Theraplex T, Zithranol) contains literally thousands of different substances that are extracted from the coal carbonization process. Coal tar is applied topically and is available as shampoo, bath oil, ointment, cream, gel, lotion, or paste. The tar decreases itching and slows the production of excess skin cells and is especially useful when used with or combined with a topical corticosteroid. It is messy and has a strong smell.
- Tree bark extract: Anthralin (Dithranol, Anthra-Derm, Drithocreme) is considered to be one of the most effective antipsoriatic agents available. It has the potential to cause skin irritation and staining of clothing and skin. Apply the cream, ointment, or paste sparingly to the skin plaques. On the scalp, rub into affected areas. Avoid the forehead, eyes, and any skin that does not have the lesions. Do not apply excessive quantities.
- Topical retinoid: Tazarotene (Tazorac) is a topical retinoid that is available as a gel or cream. Tazarotene reduces the size of the plaques and the redness of the skin. This medicine is sometimes combined with corticosteroids to decrease skin irritation and to increase effectiveness. Tazarotene is particularly useful for scalp psoriasis. Apply a thin film to the affected skin every day or as instructed. Dry skin before using this medicine. Irritation may occur when applied to damp skin. Wash hands after application. Do not cover with a bandage.
- Keratolytics: A useful addition to topical steroids is to add a keratolytic medication to remove overlying scale so that the steroid can reach the affected skin sooner and more effectively. Salicylic acid shampoos are useful in the scalp, and urea (either prescription strength or over-the-counter lower strengths) may be used on body plaques.
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References
Armstrong, April W., et al. "From the Medical Board of the National Psoriasis Foundation: Treatment Targets for Plaque Psoriasis." J Am Acad Dermatol Nov. 22, 2016: 1-9.
Burden, A.D. "Management of psoriasis in childhood." Clin Exp Dermatol 24.5 Sept. 1999: 341-5.
Feely, M.A., B.L. Smith, and J.M. Weinberg. "Novel psoriasis therapies and patient outcomes, part 1: topical medications." Cutis 95.3 Mar. 2015: 164-8, 170.
Greb, Jacqueline E., et al. "Psoriasis." Nature Reviews: Disease Primers 2 Nov. 24, 2016: 1-17.
Jensen, J.D., M.R. Delcambre, G. Nguyen, and N. Sami. "Biologic therapy with or without topical treatment in psoriasis: What does the current evidence say?" Am J Clin Dermatol 15.5 Oct. 2014: 379-85.
Kim, Whan B., Dana Jerome, and Jensen Yeung. "Diagnosis and Management of Psoriasis." Canadian Family Physician 63 April 2017: 278-285.
Mansouri, B., M. Patel, and A. Menter. "Biological therapies for psoriasis." Expert Opin Biol Ther 13.13 Dec. 2013: 1715-30.
Maza, A, et al. "Oral cyclosporin in psoriasis: a systematic review on treatment modalities, risk of kidney toxicity and evidence for use in non-plaque psoriasis." J Eur Acad Dermatol Venereol 25 Suppl 2 May 2011: 19-27.
Michalek, I.M., B. Loring, and S.M. John. "A Systematic Review of Worldwide Epidemiology of Psoriasis." JEADV 2016: 1-8.
Paul, C., et al. "Evidence-based recommendations on conventional systemic treatments in psoriasis: systematic review and expert opinion of a panel of dermatologists." J Eur Acad Dermatol Venereol 25 Suppl 2 May 2011: 2-11.
Sbidian, E., et al. "Efficacy and safety of oral retinoids in different psoriasis subtypes: a systematic literature review." J Eur Acad Dermatol Venereol 25 Suppl 2 May 2011: 28-33.
van de Kerkhof, P.C. "An update on topical therapies for mild-moderate psoriasis." Dermatol Clin 33.1 Jan. 2015: 73-7.
Villaseñor-Park, Jennifer, David Wheeler, and Lisa Grandinetti. "Psoriasis: Evolving Treatment for a Complex Disease." Cleveland Clinic Journal of Medicine 79.6 June 2012: 413-423.
Burden, A.D. "Management of psoriasis in childhood." Clin Exp Dermatol 24.5 Sept. 1999: 341-5.
Feely, M.A., B.L. Smith, and J.M. Weinberg. "Novel psoriasis therapies and patient outcomes, part 1: topical medications." Cutis 95.3 Mar. 2015: 164-8, 170.
Greb, Jacqueline E., et al. "Psoriasis." Nature Reviews: Disease Primers 2 Nov. 24, 2016: 1-17.
Jensen, J.D., M.R. Delcambre, G. Nguyen, and N. Sami. "Biologic therapy with or without topical treatment in psoriasis: What does the current evidence say?" Am J Clin Dermatol 15.5 Oct. 2014: 379-85.
Kim, Whan B., Dana Jerome, and Jensen Yeung. "Diagnosis and Management of Psoriasis." Canadian Family Physician 63 April 2017: 278-285.
Mansouri, B., M. Patel, and A. Menter. "Biological therapies for psoriasis." Expert Opin Biol Ther 13.13 Dec. 2013: 1715-30.
Maza, A, et al. "Oral cyclosporin in psoriasis: a systematic review on treatment modalities, risk of kidney toxicity and evidence for use in non-plaque psoriasis." J Eur Acad Dermatol Venereol 25 Suppl 2 May 2011: 19-27.
Michalek, I.M., B. Loring, and S.M. John. "A Systematic Review of Worldwide Epidemiology of Psoriasis." JEADV 2016: 1-8.
Paul, C., et al. "Evidence-based recommendations on conventional systemic treatments in psoriasis: systematic review and expert opinion of a panel of dermatologists." J Eur Acad Dermatol Venereol 25 Suppl 2 May 2011: 2-11.
Sbidian, E., et al. "Efficacy and safety of oral retinoids in different psoriasis subtypes: a systematic literature review." J Eur Acad Dermatol Venereol 25 Suppl 2 May 2011: 28-33.
van de Kerkhof, P.C. "An update on topical therapies for mild-moderate psoriasis." Dermatol Clin 33.1 Jan. 2015: 73-7.
Villaseñor-Park, Jennifer, David Wheeler, and Lisa Grandinetti. "Psoriasis: Evolving Treatment for a Complex Disease." Cleveland Clinic Journal of Medicine 79.6 June 2012: 413-423.