Initial treatment with topical medication

'Topical' means that something is applied to the skin. The NICE guideline does not cover the use of emollients (moisturisers) in managing psoriasis, although these may be prescribed by your doctor and can be helpful in psoriasis. It covers only topical medications that contain active ingredients to treat the psoriasis, which are referred to as topical medications in this information. You should be offered a topical medication as the initial treatment for psoriasis. If topical treatment alone is unlikely to help you because your psoriasis is widespread or you have nail disease you may also be offered additional treatments.

Your healthcare professional should offer you and/or your family or carers practical help and advice on how to use your treatment. If you have a physical disability or visual impairment that might affect your ability to apply a topical medication, you and/or your family or carers should be offered additional advice and support specific to your particular needs.

A variety of topical medications are available to treat psoriasis, including topical corticosteroids, vitamin D preparations, coal tar preparations, dithranol and calcineurin inhibitors. When deciding which treatment is most suitable for you, your healthcare professional should take into account:

  • any preferences you have

  • whether the treatment is likely to be cosmetically acceptable

  • whether there might be any practical problems with applying the treatment

  • where and how widespread the psoriasis is.

Your healthcare professional should discuss with you the different forms of medication available (such as creams, lotions, solutions, gels, mousses and ointments) and explain which might be best suited to you depending on your preferences. It is possible that you could be given more than one product to use on different parts of your body.

How to use corticosteroids safely

Topical corticosteroids are used to reduce inflammation and are available in different strengths, for example they can be mild, moderate, potent and very potent. Very potent corticosteroids should not be used to treat psoriasis in children or young people. In adults very potent corticosteroids should only be used in specialist care. This treatment needs to be carefully supervised and should only be used for up to 4 weeks.

Potent and very potent corticosteroids should not be used on the face, flexures or genitals.

It is important that you follow the advice given to you about how to use each topical corticosteroid because they can sometimes cause side effects and could even make your psoriasis worse. Your healthcare professional should explain the possible side effects and how to avoid them. If you are using potent or very potent steroids you should have a 4-week break between courses of treatment to prevent you developing side effects. You may be given a different non-steroidal topical treatment to use during this break, such as vitamin D or coal tar.

Reviewing treatment with topical medications

If you are an adult, your healthcare professional should arrange a review appointment 4 weeks after you start a new topical treatment. Children should have a review appointment 2 weeks after starting a new topical treatment.

If there is little or no improvement at this review, your healthcare professional should discuss the next treatment option with you and check if there are any reasons why the treatment is not working.

If your psoriasis is responding to topical treatment your healthcare professional should discuss with you:

  • the importance of continuing treatment until your psoriasis improves or for the length of time recommended

  • that relapse (where the psoriasis worsens again) occurs in most people after treatment is stopped

  • that after the initial treatment period topical treatments can be used as and when you need them to control your psoriasis.

You should be offered a supply of your topical treatment to keep at home to use yourself as needed.

If you are an adult and have been using potent or very potent corticosteroids, your healthcare professional should offer you annual once-yearly review to check for problems. Children and young people who have been using corticosteroids of any strength should also have their treatment reviewed once a year.

Topical treatment for trunk and limb psoriasis in adults

If you have psoriasis of the trunk or limbs you should be offered a potent corticosteroid and a vitamin D preparation as initial treatment. Each treatment should be applied once a day (one in the morning, the other in the evening) and should be used for up to 4 weeks.

If this does not improve or control your psoriasis, you should be advised to stop using the potent corticosteroid and apply only the vitamin D preparation twice a day for up to 8 weeks.

If the vitamin D preparation does not improve or control your psoriasis after 8 to 12 weeks, you should be offered one of the following treatments:

  • a potent corticosteroid to apply twice a day for up to 4 weeks or

  • a coal tar preparation applied once or twice daily or

  • a combined product containing a potent corticosteroid and vitamin D applied once a day for up to 4 weeks.

If these treatment options don't control your psoriasis, you may be referred to a specialist who may offer you other topical treatments, or other treatment options depending on how extensive your psoriasis is and the impact the psoriasis is having on your life.

For some forms of localised psoriasis where other treatments have not been successful, your healthcare professional may offer you 'short-contact' dithranol ointment or cream. To ensure it is applied correctly, you should be given educational support to help you apply it yourself or treatment should be given in a specialist setting.

Topical treatment for trunk and limb psoriasis in children and young people

If a child or a young person has trunk or limb psoriasis, their healthcare professional may offer them either:

  • a vitamin D preparation called calcipotriol applied once a day (if they are over 6 years old) or

  • a potent corticosteroid applied once a day (if they are over 1 year old).

Topical treatment for scalp psoriasis in adults, young people and children

If you have scalp psoriasis, your healthcare professional should offer you a potent corticosteroid to apply once daily for up to 4 weeks as the initial treatment. You should be shown how to apply the treatment.

If you find it difficult or cannot use corticosteroids on your scalp or you have mild to moderate scalp psoriasis, your healthcare professional may instead offer you a vitamin D preparation alone.

If this does not control your scalp psoriasis after 4 weeks you may be offered:

  • a different formulation to try (such as a shampoo or mousse) and/or

  • a scalp treatment to remove the scales (such as an emollient or oil) before further applications of the potent corticosteroid.

If after a further 4 weeks of treatment, your scalp psoriasis is still not controlled, you should be offered:

  • a combined product containing a potent corticosteroid and vitamin D applied once a day for up to 4 weeks or

  • a vitamin D preparation applied once a day (if you can't use corticosteroids and have mild to moderate scalp psoriasis).

If a combined product or vitamin D preparation does not control your scalp psoriasis after 8 weeks, you should be offered one of the following options:

  • for adults only, a very potent corticosteroid applied up to twice a day for 2 weeks

  • a coal tar preparation applied once or twice a day

  • referral to a specialist for help with topical applications or advice on other treatments.

Topical treatment for psoriasis of the face, flexures and genitals in adults, young people and children

If you have psoriasis of the face, flexures or genitals you should be offered a mild or moderate strength corticosteroid applied once or twice daily for no longer than 2 weeks.

If this treatment does not control your psoriasis or your psoriasis gets worse when you stop using it, you should be offered treatment with a calcineurin inhibitor, which should be applied twice daily for 4 weeks. A healthcare professional with expertise in treating psoriasis should start this treatment.

Your healthcare professional should also explain that topical treatments used on the face, flexures and genitals may cause irritation and that there is a greater risk of skin thinning at these areas. They should give advice on how to minimise these risks. You should also be advised to only use corticosteroids for 1–2 weeks a month.

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