Topical preparations in psoriasis (includes summary of NICE guidance)

A simple regimen for the initial topical treatment of chronic plaque psoriasis can be outlined as follows :

• 1. General measures:
  • use of a soap substitute, e.g. aqueous cream, and a bath additive e.g. Polytar emollient or Balneum with Tar, and apply a moisturiser after having a bath
    
    
• 2. Topical treatment of psoriasis affecting the trunk and limbs (2)
  
  
  • initial treatment
    • a potent corticosteroid applied once daily plus vitamin D (calcitriol) or a vitamin D analogue (calcipitriol, tacalcitol) applied once daily should be offered (applied separately, one in the morning and the other in the evening) for up to 4 weeks as initial treatment for adults with trunk or limb psoriasis
      • for example betamethasone valerate 0.025% ointment once daily plus calcipotriol ointment once daily (applied separately, one in the morning and the other in the evening)
        
        
  • if once-daily application of a potent corticosteroid plus once-daily application of vitamin D or a vitamin D analogue does not result in clearance, near clearance or satisfactory control of trunk or limb psoriasis in adults after a maximum of 8 weeks, offer vitamin D (calcitriol) or a vitamin D analogue (calcipitriol, tacalcitol) alone applied twice daily
    
    
  • if twice-daily application of vitamin D or a vitamin D analogue does not result in clearance, near clearance or satisfactory control of trunk or limb psoriasis in adults after 8-12 weeks, offer either:
    • a potent corticosteroid applied twice daily for up to 4 weeks or
    • a coal tar preparation applied once or twice daily
    • if a twice-daily potent corticosteroid or coal tar preparation cannot be used or a once daily preparation would improve adherence in adults offer a combined product containing calcipotriol monohydrate and betamethasone dipropionate (e.g. dovobet ointment) applied once daily for up to 4 weeks
      
      
  • offer treatment with very potent corticosteroids in adults with trunk or limb psoriasis only:
    • in specialist settings under careful supervision
    • when other topical treatment strategies have failed
    • for a maximum period of 4 weeks
      
      
  • short-contact dithranol should be considered for treatment-resistant psoriasis of the trunk or limbs and either:
    • give educational support for self-use or
    • ensure treatment is given in a specialist setting
      
      
  • for children and young people with trunk or limb psoriasis consider either:
    • calcipotriol applied once daily (only for those over 6 years of age) or
    • a potent corticosteroid applied once daily (only for those over 1 year of age).
• 3. Topical treatment of psoriasis affecting the scalp (2)
  
  • a potent corticosteroid applied once daily should be offered for up to 4 weeks as initial treatment for people with scalp psoriasis
    • for example betnovate scalp application applied once daily for up to 4 weeks
      
    • if treatment with a potent corticosteroid does not result in clearance, near clearance or satisfactory control of scalp psoriasis after 4 weeks consider:
      • a different formulation of the potent corticosteroid (for example, a shampoo or mousse) and/or
      • topical agents to remove adherent scale (for example, agents containing salicylic acid, emollients and oils) before application of the potent corticosteroid
        • for example cocois ointment, 5% salicylic acid in emulsifying ointment
          
          
  • if the response to treatment with a potent corticosteroid for scalp psoriasis remains unsatisfactory after a further 4 weeks of treatment offer:
    • a combined product containing calcipotriol monohydrate and betamethasone dipropionate applied once daily (e.g. xamiol scalp gel) for up to 4 weeks or
    • vitamin D or a vitamin D analogue applied once daily (only in those who cannot use steroids and with mild to moderate scalp psoriasis) (e.g. calcipotriol scalp application)
      
      
  • if continuous treatment with either a combined product containing calcipotriol monohydrate and betamethasone dipropionate applied once daily or vitamin D or a vitamin D analogue applied once daily for up to 8 weeks does not result in clearance, near clearance or satisfactory control of scalp psoriasis offer
    • a very potent corticosteroid applied up to twice daily for 2 weeks for adults only or
    • coal tar applied once or twice daily or
    • referral to a specialist for additional support with topical applications and/or advice on other treatment options
      
      
  • topical vitamin D or a vitamin D analogue alone should be considered for the treatment of scalp psoriasis only in people who:
    • are intolerant of or cannot use topical corticosteroids at this site or
    • have mild to moderate scalp psoriasis
      
      
  • do not offer coal tar-based shampoos alone for the treatment of severe scalp psoriasis
• 4. Topical treatment of psoriasis affecting the face, flexures and genitals (2)
  • offer a short-term mild or moderate potency corticosteroid applied once or twice daily (for a maximum of 2 weeks) to people with psoriasis of the face, flexures or genitals e.g.hydrocortisone 1% ointment applied once or twice daily
    • corticosteroids should only be used for short-term treatment of psoriasis affecting these arease (1-2 weeks per month)
    • for adults with psoriasis of the face, flexures or genitals if the response to short-term moderate potency corticosteroids is unsatisfactory, or they require continuous treatment to maintain control and there is serious risk of local corticosteroid-induced side effects, offer a calcineurin inhibitor applied twice daily for up to 4 weeks. Calcineurin inhibitors should be initiated by healthcare professionals with expertise in treating psoriasis
    • do not use potent or very potent corticosteroids on the face, flexures or genitals

Notes:

• aim for a break of 4 weeks between courses of treatment with potent or very potent corticosteroids
  • consider topical treatments that are not steroid-based (such as vitamin D or vitamin D analogues or coal tar) as needed to maintain psoriasis disease control during this period
• when offering a corticosteroid for topical treatment select the potency and formulation based on the person's need
  • do not use very potent corticosteroids continuously at any site for longer than 4 weeks
  • do not use potent corticosteroids continuously at any site for longer than 8 weeks
  • do not use very potent corticosteroids in children and young people
    
    
• arrange a review appointment 4 weeks after starting a new topical treatment in adults, and 2 weeks after starting a new topical treatment in children, to
  • evaluate tolerability, toxicity, and initial response to treatment
  • reinforce the importance of adherence when appropriate
  • reinforce the importance of a 4 week break between courses of potent/very potent corticosteroids

Reference:

• 1. . NICE (September 2017). Psoriasis - the assessment and management of psoriasis