Topical therapies for psoriasis work relatively quickly by clearing the skin lesions and are also usually well tolerated. However, they can be messy and may not be useful in the generalized variety of psoriasis.
Common topical agents used are:
Topical Corticosteroids in Psoriasis
Topical corticosteroids are synthetic drugs that resemble naturally-occurring hormones in the body. Corticosteroids are the most frequently prescribed treatment for mild to moderate psoriasis because they decrease the rate at which skin cells grow and reduce inflammation, thereby also relieving the itch that often accompanies psoriasis.
Prolonged use and over a large area of the body can cause steroid side effects like skin thinning and normal body hormone production suppression. Hence steroids have to be used very judiciously. Potent topical steroids like clobetasole propionate should be used only up to a maximum of 50 gm ointment per week.
Calcipotriene in Psoriasis
Calcipotriene was first approved in the early 1990s in Europe as a 0.005% ointment formulation with the generic name calcipotriol. It is an analogue of vitamin D3, and in clinical trials it was shown to be comparable to or slightly better than class II corticosteroid ointments such as fluocinonide 0.05%. In trials in which calcipotriol was compared with anthralin, it fared well in terms of clinical efficacy and was preferred by patients because it does not stain as much as anthralin and is less irritating.
Sequential Therapy in Psoriasis
Calcipotriene is not as effective as super potent topical corticosteroids, but regimens in which patients apply both calcipotriene and super potent corticosteroids in an alternating dosage schedule have demonstrated superiority over either agent used alone.
Salicylic Acid in Psoriasis
Salicylic acid is a keratolytic agent that helps remove the thick scale on psoriasis lesions. The other topical medications can penetrate better if used after salicylic acid or in combination with it. It can be applied as a paste or in creams/ointments/lotions in concentrations of 2-6%.
Coal Tar in Psoriasis
Topical coal tars have helped treat psoriasis for centuries and can be used by themselves or combined with UVB phototherapy. They are also used along with anthralin. However, coal tar causes staining and is also a designated skin carcinogen, which limits its usage in the fair skinned.
Goeckerman’s Regimen in Psoriasis
Even after half a century, this regimen is still found useful in many patients, especially the dark skinned.
Steps in Goeckerman Regimen:
- Topical application of crude coal tar in petrolatum, at night.
- Oil bath in the morning to wash off the scales and the remaining topical application
- Progressively increasing sun exposure after bath, to induce mild degree of erythema (redness) on the skin.
Anthralin in Psoriasis
Since the introduction of newer topical therapies like vitamin D analogs for psoriasis, anthralin use has declined because of the side effects of staining and irritation. Recently, the development of new vehicles has led to better acceptance of anthralin for the treatment of psoriasis. Micanol is a 1% anthralin formulation in a temperature-sensitive vehicle that releases the active medication at skin surface temperatures. Short contact therapies are popular with anthralin to limit its irritation.
Tazarotene in Psoriasis
Retinoids (vitamin A derivatives) are the most recent developments in the topical treatment of psoriasis. Tazarotene, in 05-0.1% strength is a retinoid for mild to moderate plaque psoriasis, which can be used on the body, including the face, hairline and scalp. Local irritation caused by retinoids has limited their use. Various combinations with steroids are tried to reduce irritation and enhance effectiveness.
Calcineurin Inhibitors in Psoriasis
Calcineurin inhibitors, such as tacrolimus ointment and pimecrolimus cream, have been found to be effective in treating psoriasis. Calcineurin inhibitors interfere with the activation of T-cells, a type of white blood cell responsible for triggering immune responses that contribute to the development of psoriasis.
Emollients in Psoriasis
Emollients like vaseline, 10% urea etc., are effective in controlling the excessive shedding of scales in psoriasis. Emollients alone are used in self limiting forms like guttate psoriasis. They are also useful in removing the adherent scales. After soaking the scales in water, emollients are rubbed in well and later firmly wiped off to remove the scales. Emollients are useful vehicles to gradually reduce the strength of super potent cortico steroids as the psoriasis plaques improve.
Further Reading: Topical Corticosteroids in Psoriasis
DisclaimerThe 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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