PRACTICE RECOMMENDATIONS
• Prescribe high-potency (Class 1) topical steroids for use on thicker, chronic plaques and low-potency (Class 7) steroids for the face, intertriginous areas, and the groin. A
• Recommend folate supplementation (1-5 mg/d) for patients being treated with methotrexate, as it may reduce the drug’s hematologic and gastrointestinal adverse effects without decreasing efficacy. A
• Advise patients scheduled to begin biologic therapy to get standard vaccinations—eg, pneumococcal, influenza, hepatitis A and B—before treatment is initiated and to avoid live and live-attenuated vaccines thereafter. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Psoriasis is a systemic inflammatory disorder altered by environmental and genetic factors that presents as scaly erythematous plaques and affects 2% to 3% of the population.1 Eighty percent have mild-to-moderate cutaneous disease; disabling arthritis occurs in as many as 42% of cases.1,2 The devastating effects on quality of life— including social stigmatization, pain, physical disability, and psychological distress—are comparable to the effects of conditions like cancer and depression.2 There is no definitive cure, and patients are left with a lifetime of waxing and waning symptoms.
Helping to create an individualized treatment plan tailored to disease type and extent, comorbidities, and needs of the patient can directly impact the quality of his or her life.3 For those with localized disease, topical therapy is a suitable first choice. Phototherapy is generally the first-line treatment for patients with extensive psoriasis or disabling symptoms. When phototherapy is not feasible or is ineffective, systemic treatments with conventional oral agents or biologics are indicated.
Discussions about therapeutic options should include expected results and duration of remission, cost, convenience, adverse effects, insurance coverage, and safety concerns. The patient’s preferences should be taken into account in the treatment plan you create.3 A guiding principle: The optimal protocol is the one the patient is motivated to adhere to.
The limits of topical therapy
Topical treatments are safe and effective when used properly, as monotherapy for localized disease and adjunctive therapy for resistant lesions. Monotherapy with topical agents is not recommended for sites that have a significant impact on quality of life, such as the palms and soles, and is not practical for patients with extensive disease (>10% of body surface).4
More potent topicals, such as corticosteroids, are recommended for acute flares; less potent agents with fewer adverse effects, such as calcipotriene, are typically used for maintenance ( TABLE 1 ).5-8 Topical agents can be used either long term or intermittently. Here, too, the most effective treatment is the one the patient will actually apply.5
TABLE 1
A look at nonsteroidal topical treatments5-8
| Class | Examples | Adverse effects | Comments |
|---|---|---|---|
| Vitamin D analogues | Calcipotriol (calcipotriene), calcitriol | Burning, pruritus, edema, peeling, dryness, erythema | Combining with beta-methasone dipropionate increases efficacy |
| Retinoids | Tazarotene, tretinoin | Teratogenic, photosensitivity, irritation | Increased efficacy when combined with NB-UVB (and less UV exposure); increased efficacy, duration of remission, and reduction in steroid-induced atrophy when used with steroids |
| Calcineurin inhibitors | Tacrolimus, pimecrolimus | Burning and pruritus Black box warning for risk of malignancies* | No clinical evidence of increased cancer risk |
| Others | Emollients, salicylic acid, anthralin, coal tar | Severe skin irritation, staining of clothes, odor with anthralin and tar | Salicylic acid works well with steroids and topical immunomodulators, but is not compatible with calcipotriene |
| *Lymphoma seen with oral therapy. UVB, ultraviolet B; NB-UVB, narrow-band ultraviolet B. | |||
Steroid selection is based on site, severity
Corticosteroids are antiproliferative, immunosuppressive, anti-inflammatory, and vasoconstrictive, and divided into 7 classes. Low-potency agents (Class 7) are used on thinner skin like the face, intertriginous areas, and groin; high-potency steroids (Class 1) are reserved for thicker, chronic plaques.9 As a general rule, Class 1 steroids can be safely used for 2 to 4 weeks, with increased risk of both cutaneous effects and systemic absorption if used continuously for longer periods.5 The optimal end point for less potent agents is not known.
Cutaneous adverse effects are more common than systemic ones and include skin atrophy, telangiectasia, striae distensae, acne, folliculitis, and purpura.
Systemic adverse effects include Cushing’s syndrome, osteonecrosis of the femoral head, cataracts, and glaucoma.5 The greatest risk of systemic effects is associated with prolonged use of high-potency corticosteroids over large surfaces or under occlusion with dressings or plastic wrap. Patients should be transitioned to the lowest potency possible to maintain efficacy, use corticosteroids intermittently, or combine them with nonsteroidal agents to avoid unwanted effects.