Topical treatments for psoriasis
Mild psoriasis can usually be treated effectively using medication applied directly to the skin (topical treatments). Corticosteroids and vitamin D analogues have proven to help and be well tolerated.
The treatment options for psoriasis include medication applied to the skin, phototherapy, and medication that is swallowed or injected. Topical (externally applied) treatments are often effective in mild to moderate cases of psoriasis. The medications are applied to the affected areas of skin (plaques) in the form of ointments, creams, solutions or foams. The type of product used will depend on various factors, including the location of the plaque and the condition of the skin.
Some people only use the medication during acute episodes of psoriasis, while others use it regularly as a long-term treatment. It is then applied to the affected areas of skin during "quieter" phases too, with the aim of preventing further flare-ups. In order to avoid side effects, steroid medications aren't applied every day, but rather on two days per week – for instance at weekends.
In addition to using medicated topical treatments, people are advised to take good care of their skin, for instance by using lipid-replenishing ointments or creams (emollients) to moisturize it. The aim of this continuous basic treatment is to relieve itching and prevent the skin from drying out.
Treatment with topical corticosteroids
Corticosteroids (sometimes simply referred to as “steroids”) reduce inflammation and slow the rapid production of skin cells. They are applied to the skin in the form of a cream, solution, ointment or – for the treatment of psoriasis on the scalp – a foam or shampoo.
There are big differences between corticosteroids in terms of the strength of their effect (their potency). In Germany and other countries they are divided up into four groups based on their potency:
- Low-potency corticosteroids (class I)
- Moderate-potency corticosteroids (class II)
- High-potency corticosteroids (class III)
- Ultra-high-potency corticosteroids (class IV)
Ultra-high-potency corticosteroids are often needed for the treatment of very scaly areas of skin and psoriasis on hair-covered areas of the scalp. Weaker corticosteroids or other drugs are used on sensitive areas of the body, such as the face or in skin folds. The symptoms usually improve within one to two weeks of starting treatment.
Psoriasis flare-ups are often treated with stronger medications such as mometasone. These medications are generally applied to the affected areas of skin once or twice a day for the first three weeks. After that they are gradually applied less frequently – for instance, every other day in the fourth week, and every three days in the fifth week. Treatment with topical steroids is stopped gradually because an abrupt stop can make psoriasis come back again.
Studies have shown high-potency corticosteroids to be effective. They found the following after a few weeks:
- Without the corticosteroid treatment, about 10 out of 100 people had hardly any or no visible psoriasis plaques.
- With the corticosteroid treatment, about 45 out of 100 people had hardly any or no visible psoriasis plaques.
In other words, the corticosteroids led to a clear improvement in psoriasis symptoms in 35 out of 100 people.
If treatment with a high-potency corticosteroid isn’t effective enough, the ultra-high-potency corticosteroid “clobetasol” can be tried out. This medication was shown to be even more effective than high-potency (class III) medications.
Side effects are rare
A lot of people are wary of using steroids, and afraid of side effects such as the skin becoming thinner. But this rarely happens when steroids are used for a limited amount of time only. Studies found that 1 to 2 out of 100 people’s skin became thinner following treatment with topical corticosteroids, particularly ultra-high-potency corticosteroids. Nobody stopped their treatment due to side effects, though.
Some people are worried about serious side effects such as metabolic disorders or high blood pressure. As a result, they don’t use their corticosteroid cream or ointment for long enough, or they apply too little. But the risk of topical corticosteroids causing serious side effects is extremely small if they are used properly.
Calcipotriol (also known as calcipotriene) is a vitamin D analogue. Other examples of vitamin D analogues include calcitriol and tacalcitol. They are only rarely used in the treatment of psoriasis, though.
The chemical structure of calcipotriol is similar to that of vitamin D3 and corticosteroid medications. It is applied to the skin once or twice a day in the form of a cream, gel, ointment or solution. This treatment shouldn’t be used on more than 30% of the body’s surface area.
Calcipotriol has also been shown to be an effective treatment in studies. But it is currently thought to be slightly less effective than high-potency corticosteroids. It is also more likely to cause local side effects such as burning or itching.
If treatment with one medication alone doesn’t help enough, a vitamin D analogue can be combined with a steroid medication. Ready-made medications containing a fixed combination of calcipotriol and betamethasone are available too.
Other topical treatments
Dithranol and coal tar
Older topical treatments for psoriasis, such as dithranol and coal tar, are only rarely used nowadays. One reason for this is because they aren’t very easy to use compared with topical corticosteroids or calcipotriol: They can stain your skin and clothing, and many people find the smell of coal tar unpleasant. But dithranol is still often used in hospitals and other inpatient settings.
Calcineurin inhibitors: Pimecrolimus and tacrolimus
If psoriasis affects sensitive areas of skin – for instance on your face, in your groin area or your armpits – calcineurin inhibitors are sometimes used as an alternative to corticosteroids. This group of medications includes creams and ointments containing pimecrolimus and tacrolimus. Tacrolimus is the stronger of the two drugs.
Unlike steroids, calcineurin inhibitors don’t make your skin thinner. But they were originally developed for the treatment of eczema and haven’t been approved for the treatment of psoriasis. So certain things have to be taken into consideration if they are used for the treatment of psoriasis. For instance, it’s important to contact your health insurer before starting the treatment in order to find out whether they will cover the costs.
Also, there’s a lack of good-quality research on the effectiveness of calcineurin inhibitors in the treatment of psoriasis, so it’s difficult to say whether they work as well as corticosteroids do.
Choosing a suitable topical treatment
The choice of medication will depend on many different factors. Research has shown that treatment with topical corticosteroids is the most effective and also well tolerated. So people who are starting treatment for psoriasis are usually given topical steroids.
If a psoriasis treatment is needed for more than several weeks and you want to avoid the possible long-term side effects of steroids, treatment with a different medication such as calcipotriol may be more suitable.
Mason AR, Mason J, Cork M, Dooley G, Hancock H. Topical treatments for chronic plaque psoriasis. Cochrane Database Syst Rev 2013; (3): CD005028.
National Institute for Health and Care Excellence (NICE). Psoriasis: Assessment and Management of Psoriasis. October 24, 2012. (NICE Guidelines; volume 153).
Schlager JG, Rosumeck S, Werner RN, Jacobs A, Schmitt J, Schlager C et al. Topical treatments for scalp psoriasis: summary of a Cochrane Systematic Review. Br J Dermatol 2017; 176(3): 604-614.
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