Management and Treatment of Psoriasis with Topical Therapy and Alternative Medicine Modalities for Psoriasis Severity Measures

Publication Date: July 1, 2020
Last Updated: July 31, 2022

Recommendations

Topical steroids

The use of class 1, class 2, and class 3-5 topical steroids for up to 4 weeks is recommended for the treatment of plaque psoriasis not involving intertriginous areas. (Level I, A)
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The use of class 1-7 topical steroids for a minimum of up to 4 weeks is recommended as initial and maintenance treatment of scalp psoriasis. (Level I, A)
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The use of topical corticosteroids for >12 weeks can be considered if done under the careful supervision of a physician.

(Level III, C)
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Topical Pimecrolimus and Tacrolimus

The off-label use of 0.1% Tacrolimus for psoriasis involving the face as well as inverse psoriasis for up to 8 weeks can be considered. (Level I, B)
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The off-label use of Pimecrolimus for inverse psoriasis for 4-8 weeks is recommended. (Level I, B)
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Long term use of Tacrolimus or Pimecrolimus can be considered for inverse psoriasis treatment as off-label use. (Level III, C)
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The off-label combination of Tacrolimus and 6% salicylic acid for 12 weeks may be used for the treatment of plaque psoriasis. (Level II, B)
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Vitamin D analogues

The long-term use of topical vitamin D analogues (up to 52 weeks) including calcipotriene/calcipotriene, calcitriol, tacalcitol, and maxacalcitol is recommended for the treatment of mild to moderate psoriasis. (, A)
(I-II)
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Use of calcipotriene foam and calcipotriene plus betamethasone dipropionate gel is recommended for 4-12 weeks for the treatment of mild to moderate scalp psoriasis. (Level I, A)
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Topical tacalcitol ointment or calcipotriene combined with hydrocortisone for 8 weeks can be used for the treatment of facial psoriasis. (, B)
(I-II)
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Combination treatments with vitamin D analogues and potent topical steroids for psoriasis. (, A)
(I-II)
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Use of combination products with calcipotriol and corticosteroids is recommended for the treatment of psoriasis. (, A)
(I-III)
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The application of vitamin D analogues twice daily on weekdays in conjunction with high potency topical steroids twice daily on weekends can be considered for maintenance treatment for psoriasis. (Level II, B)
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The application of morning high potency topical steroids and evening topical vitamin D analogues is an effective treatment regimen that can be considered for the treatment of psoriasis. (Level II, B)
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Topical tazarotene

Topical tazarotene can be used for the treatment of mild to moderate psoriasis. (, B)
(I-III)
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Topical tazarotene can be used for the treatment of nail psoriasis. (, B)
(I-II)
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The combination of topical tazarotene and NB-UVB has been shown to be effective and allow a reduction in total usage of NB-UVB. (Level II, B)
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The use of mid-potency or high potency topical steroid in combination with tazarotene for 8-16 weeks is more effective than monotherapy with tazarotene and is recommended for the treatment of mild to moderate psoriasis. (Level I, A)
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The use of topical steroids along with tazarotene is recommended to decrease the duration of treatment as well as increase the length of remission. (Level I, A)
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Emollient

The use of an emollient in conjunction with topical corticosteroids for 4 to 8 weeks can be used to help reduce itching, desquamation, and total body surface area and prevent quick relapse of psoriasis when topical corticosteroids are discontinued. (Level II, B)
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Salicylic acid

Topical salicylic acid can be used for 8-16 weeks for the treatment of mild to moderate psoriasis. (, B)
(I-II)
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The combination of salicylic acid with topical corticosteroids can be used for the treatment of moderate to severe psoriasis (BSA ≤20%). (Level I, B)
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Topical anthralin

Topical anthralin for 8-12 weeks can be used for the treatment of mild to moderate psoriasis. Short contact (up to 2 hours per day) anthralin is recommended to limit side effects. (, B)
(I-III)
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Coal tar

Coal tar preparations are recommended for the treatment of mild to moderate psoriasis. (, A)
(I-II)
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According to the joint AAD-NPF phototherapy guideline, there is sufficient evidence to recommend the use of Goeckerman therapy for the treatment of psoriasis. (, B)
(II-III)
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Combination of topical agents with biologics

The addition of an ultra-high potency (Class 1) topical corticosteroid to standard dose etanercept for 12 weeks is recommended for the treatment of moderate to severe psoriasis. (Level I, A)
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The addition of calcipotriene/betamethasone to standard dose adalimumab for 16 weeks is recommended for the treatment of moderate to severe psoriasis to accelerate clearance of psoriatic plaques. (Level I, B)
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All topical steroids can be used in combination with any biologics for the treatment of moderate to severe psoriasis. (Level III, C)
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Combination of topical calcipotriene and methotrexate

The addition of topical calcipotriene to standard dose methotrexate therapy is recommended for the treatment of moderate to severe psoriasis. It may lead to lower cumulative doses of methotrexate and increased time to relapse following methotrexate discontinuation. (Level I, A)
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Combination of topical agents and cyclosporine

The addition of calcipotriene/betamethasone dipropionate ointment to low dose (2 mg/kg/day) cyclosporine can be used for the treatment of moderate to severe psoriasis. (Level I, B)
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Combination of calcipotriene and acitretin

The addition of calcipotriene to standard dose acitretin is recommended for the treatment of moderate to severe psoriasis. (Level I, A)
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BSA severity measure

Body surface area (BSA) measurement of involved skin is recommended as an important measure of psoriasis severity to risk stratify patient for future co-morbidities and to assess response to treatment. (, B)
(II-III)
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PASI severity measure

Psoriasis area and severity index (PASI) is a commonly used outcome measure in clinical trials. However, it is seldom used in clinical practice to assess the severity. (Level III, B)
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PGA severity measure

Physician global assessment (PGA) measurement of psoriasis is suggested as an important measure to assess psoriasis severity. (, B)
(I-III)
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PGA x BSA severity measure

Physician global assessment x Body surface area (PGAxBSA) is recommended as an important measure of psoriasis severity. (Level II, B)
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PSI severity measure

The Psoriasis Symptom Inventory (PSI) is recommended as an important patient-reported measure of psoriasis severity with utility in clinical trials. PSI is a new quality of life instrument and has potential to be used in clinical practice and clinical trials. (, C)
(I-II)
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DLQI severity measure

Dermatology Life Quality Index (DLQI) measurement of psoriasis is recommended as an important measure of psoriasis severity with utility in clinical trials and is seldom used in clinical practice. (, B)
(II-III)
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Pruritus assessment severity measure

Pruritus is a significant symptom of psoriasis. An itch severity assessment is recommended to appropriately assess the degree of pruritus when present. (, B)
(II-III)
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Recommendation Grading

Abbreviations

  • AAD: American Academy Of Dermatology
  • LCD: Liquor Carbonis Detergens
  • UVA: Ultraviolet A Light
  • UVB: Ultraviolet B Light

Disclaimer

Overview

Title

Management and Treatment of Psoriasis with Topical Therapy and Alternative Medicine Modalities for Psoriasis Severity Measures

Authoring Organizations

Publication Month/Year

July 1, 2020

Last Updated Month/Year

July 10, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult

Health Care Settings

Ambulatory

Intended Users

Physician, nurse, nurse practitioner, physician assistant

Scope

Management, Treatment

Diseases/Conditions (MeSH)

D011565 - Psoriasis, D012871 - Skin Diseases

Keywords

psoriasis, alternative medicine, Clinical guidelines for psoriasis, topical agents, severity assessment, dermatology, skin disease

Source Citation

Elmets CA, Korman NJ, Prater EF, Wong EB, Rupani RN, Kivelevitch D, Armstrong AW, Connor C, Cordoro KM, Davis DMR, Elewski BE, Gelfand JM, Gordon KB, Gottlieb AB, Kaplan DH, Kavanaugh A, Kiselica M, Kroshinsky D, Lebwohl M, Leonardi CL, Lichten J, Lim HW, Mehta NN, Paller AS, Parra SL, Pathy AL, Siegel M, Stoff B, Strober B, Wu JJ, Hariharan V, Menter A. Joint AAD-NPF Guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures. J Am Acad Dermatol. 2021 Feb;84(2):432-470. doi: 10.1016/j.jaad.2020.07.087. Epub 2020 Jul 30. PMID: 32738429.

Methodology

Number of Source Documents
274
Literature Search Start Date
January 1, 2008
Literature Search End Date
December 31, 2017