Topical Sequential Therapy in Psoriasis
A Corticosteroid Calcipotriene Combination Therapy.
Dec 31, 2008
Topical therapy is indicated for psoriasis patients whose affected body area is less than 10-20% of their skin, the mainstay being topical corticosteroids. However, long term side effects of topical cortico steroids limit their use in psoriasis. On the other hand, calcipotriene, a vitamin D3 derivative topical agent used in psoriasis is comparatively safe, but not as effective as steroids in controlling psoriasis. It has been shown that regimens in which patients apply both calcipotriene and super potent corticosteroids have demonstrated superiority over either agent used alone.
Clinical Studies on Sequential Therapy for Psoriasis
In a study conducted more than a decade ago, a regimen was examined in which calcipotriene ointment was applied in the morning and halobetasol ointment applied in the evening for 2 weeks. That regimen proved to be superior to monotherapy with halobetasol ointment twice daily or calcipotriene ointment twice daily for 2 weeks.
A second study looked at a long-term maintenance regimen using halobetasol ointment twice daily weekends only and calcipotriene ointment twice daily on weekdays, i.e., 5 days calcipotriene and two days halobetasole. This regimen was found to be superior to a “weekends only” regimen of halobetasol ointment with placebo applied twice daily on weekdays. With halobetasol and calcipotriene, 76% of patients were able to maintain remission for 6 months compared with only 40% of patients using halobetasol and placebo.
Phases of Topical Sequential Therapy in Psoriasis
Topical sequential therapy in psoriasis involves three phases:
- Clearance Phase: Short term daily therapy with two topical agents. A class 1(super potent) corticosteroid like clobetasole or halobetasole is applied in the morning to the psoriasis plaques, followed by application of calcipotriene at night. Some dermatologists advocate a combination of calcipotriene with betamethasone dipropionate in a single ointment base, to be applied twice daily, during this stage. This phase usually lasts 2-4 weeks.
- Transition Phase: Once the lesions have responded to the above combination therapy, the patient enters the transition phase of the sequential therapy. During this period, the topical steroid application is reduced from daily application to use only on weekends (2 days), while calcipotriene is applied on weekdays (5 days). This is also called pulse therapy and this phase may last anywhere between 1 month to 6 months. The steroid application is gradually reduced and finally withdrawn in the next phase.
- Maintenance Phase: During this period, only calcipotriene is used, till the lesions clear completely and stay cleared.
Sequential therapy is indeed an excellent topical therapy for patients with a limited area of psoriasis plaques.
Next: Is Coal Tar Treatment in Psoriasis Outdated?
Reference
- Lebwohl M, Yoles A, Lombardi K, Lou W. Calcipotriene ointment and halobetasol ointment in the long-term treatment of psoriasis: effects on the duration of improvement. J Am Acad Dermatol 39(3):447-50 (1998 ).
- Koo JYM. How and why to employ sequential therapy for psoriasis. Skin and Aging Suppl:16-21 (2000).
Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or suite101 will not be responsible for any consequences. The images provided are for illustration purpose only.
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