Alternatives include vitamin D analogs, such as calcipotriene and calcitriol, tar, and topical retinoids (tazarotene). Severe psoriasis requires phototherapy or systemic therapies such as retinoids, methotrexate, cyclosporine, apremilast, or biologic immune modifying agents. Topical calcipotriene or calcitriol and the topical calcineurin inhibitors tacrolimus or pimecrolimus are additional first-line treatments 8,9. BACKGROUND: Most psoriasis patients suffering from mild to moderate disease are treated with first-line topical treatments, including corticosteroids, vitamin D analogues, topical retinoids and calcineurin inhibitors. We intended to systematically review all available literature on the efficacy and safety of combinations of first-line topicals in chronic plaque psoriasis, and ultimately, to propose recommendations for combined regimens concerning first-line treatments. The most common clinical variant is plaque-type psoriasis, characterized by erythematous scaly plaques, round or oval, variable in size, frequently located in scalp, lower back, umbilical region, intergluteal cleft, knees, and elbows 1, 5, 6. Topical vitamin D analogues (calcitriol, tacalcitol, and calcipotriol);
When topical corticosteroids are used to treat psoriasis, it is recommended that a gradual reduction in the frequency of usage following clinical response be instituted, although the exact details of this tapering are not well established. Topical corticosteroids may exacerbate preexisting or coexistent dermatoses, such as rosacea, perioral dermatitis, and tinea infections and may on occasion cause contact dermatitis. Pursuit of these goals with agents including vitamin D analogues, topical retinoids, and calcineurin inhibitors has shown benefit. Most psoriasis patients are treated with topicals. Topical Vitamin D3 Analogs. It is important to base the choice of plaque psoriasis treatment on disease severity, any contraindications to specific treatments a patient may have, cost, and the potential for adverse effects. This review will focus on currently available treatment options and the evidence supporting their use. Mild to moderate psoriasis can often be treated with topical agents such as corticosteroids, retinoids, vitamin D analogues, and moisturizers that are applied directly to the affected area. Topical calcineurin inhibitors: Tacrolimus and pimecrolimus.
Treatment of plaque psoriasis focuses on topicals such as corticosteroids, vitamin D analogues, retinoids, and calcineurin inhibitors. The chronic nature of psoriasis is often frustrating for both patients and physicians alike. Many options for treatment exist, though successful disease management rests largely on patients through the application of topical corticosteroids, Vitamin D analogs, and calcineurin inhibitors, amongst others and the administration of systemic medications such as biologics and methotrexate. Figure 1 Clinical presentation of plaque-type psoriasis demonstrating well demarcated erythematous plaques with overlying adherent scale. M518101 (Maruho Co, Ltd) is a novel topical vitamin D3 analogue. Phase 1 (NCT01844973) and phase 2 (NCT01301157, NCT00884169) trials evaluating the safety, pharmacokinetics, and efficacy of M518101 have been completed; results were not available at the time of publication.
Psoriasis: Recommendations For Topical Corticosteroids
Key Words: psoriasis, topical therapies, corticosteroids, vitamin D analogues, steroid foams. Steroids are also excellent constituents to compound with other effective antipsoriatic agents, such as salicylic acid and liquor carbonis detergens (LCD). The mechanism of action of retinoids in psoriasis may include direct suppression of inflammation, as well as inhibition of proliferation and normalization of differentiation in the epidermal layer. Hence, it led to the belief that the penetration of topical calcineurin inhibitors into thick psoriatic plaques was limited. Plaque psoriasis is the most prevalent form of the disease. Topical corticosteroids are the mainstay of treatment. I will assess only first-line topical therapy, which includes corticosteroids, vitamin D analogs, retinoids, and keratolytic agents. Once remission has been established, topical corticosteroids can be applied two days out of the week to prevent a flare. Second line treatment includes topical calcineurin inhibitors (tacrolimus and pimecrolimus). The most common, and most likely to be tested is plaque psoriasis. Second line options include vitamin D analogs, coal tar, and topical retinoids. In addition to the mainstays of treatment, such as oral or topical antibiotics and anti-inflammatory agents described in Table 2, several products designed to treat rosacea have gained recent approval from the FDA. Topical calcineurin inhibitors are recommended in a variety of eyelid dermatitides, given that they do not thin or lighten the skin in the way a corticosteroid may over time. Silvery, white scale overlying the erythematous plaque on the leg in a patient with psoriasis. Vitamin D analogues, such as calcipotriene, which inhibit keratinocyte proliferation and differentiation, also are effective. Other treatments include dithranol ointment, PUVA, and drugs such as methotrexate. The most common form of psoriasis, chronic plaque psoriasis or psoriasis vulgaris, accounts for 90 of cases. All vitamin D3 analogues directly inhibit keratinocyte proliferation, but also switch intraplaque cytokines from a Th1 to a Th2 profile. The calcineurin inhibitor tacrolimus, although only approved for the treatment of atopic dermatitis, has an advantage over topical corticosteroids in that it does not produce skin atrophy.