Journal of the American Academy of Dermatology
Volume 60, Issue 4 , Pages 643-659 , April 2009

Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies

  • Alan Menter, MD (Chair)

      Affiliations

    • Baylor University Medical Center, Dallas, Texas
  • ,
  • Neil J. Korman, MD, PhD

      Affiliations

    • Department of Dermatology, Murdough Family Center for Psoriasis, Department of Dermatology, University Hospitals Case Medical Center, Cleveland, Ohio
  • ,
  • Craig A. Elmets, MD

      Affiliations

    • Department of Dermatology, University of Alabama at Birmingham, Birmingham, Alabama
  • ,
  • Steven R. Feldman, MD, PhD

      Affiliations

    • Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
  • ,
  • Joel M. Gelfand, MD, MSCE

      Affiliations

    • Department of Dermatology and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
  • ,
  • Kenneth B. Gordon, MD

      Affiliations

    • Division of Dermatology, Evanston Northwestern Healthcare and Department of Dermatology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
  • ,
  • Alice Gottlieb, MD, PhD

      Affiliations

    • Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
  • ,
  • John Y.M. Koo, MD

      Affiliations

    • Department of Dermatology, University of California–San Francisco, San Francisco, California
  • ,
  • Mark Lebwohl, MD

      Affiliations

    • Department of Dermatology, Mount Sinai School of Medicine, New York, New York
  • ,
  • Henry W. Lim, MD

      Affiliations

    • Department of Dermatology, Henry Ford Hospital, Detroit, Michigan
  • ,
  • Abby S. Van Voorhees, MD

      Affiliations

    • Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
  • ,
  • Karl R. Beutner, MD, PhD

      Affiliations

    • Department of Dermatology, University of California–San Francisco, San Francisco, California
    • Anacor Pharmaceuticals, Inc, Palo Alto, California
  • ,
  • Reva Bhushan, PhD

      Affiliations

    • American Academy of Dermatology, San Francisco, California
    • Corresponding Author InformationReprint requests: Reva Bhushan, PhD, 930 E Woodfield Rd, Schaumburg, IL 60173.

References 

  1. Menter A, Gottlieb A, Feldman SR, Van Voorhees AS, Leonardi CL, Gordon KB, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol. 2008;58:826–850
  2. Gottlieb A, Korman NJ, Gordon KB, Feldman SR, Lebwohl M, Koo JY, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol. 2008;58:851–864
  3. Ebell MH, Siwek J, Weiss BD, Woolf SH, Susman JL, Ewigman B, et al. Simplifying the language of evidence to improve patient care: strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in medical literature. J Fam Pract. 2004;53:111–120
  4. Nast A, Kopp IB, Augustin M, Banditt KB, Boehncke WH, Follmann M, et al. Evidence-based (S3) guidelines for the treatment of psoriasis vulgaris. J Dtsch Dermatol Ges. 2007;(5 Suppl 3):1–119
  5. Smith CH, Anstey AV, Barker JN, Burden AD, Chalmers RJ, Chandler D, et al. British Association of Dermatologists guidelines for use of biological interventions in psoriasis 2005. Br J Dermatol. 2005;153:486–497
  6. Krueger GG, O'Reilly MA, Weidner M, Dromgoole SH, Killey FP. Comparative efficacy of once-daily flurandrenolide tape versus twice-daily diflorasone diacetate ointment in the treatment of psoriasis. J Am Acad Dermatol. 1998;38:186–190
  7. Bruner CR, Feldman SR, Ventrapragada M, Fleischer AB. A systematic review of adverse effects associated with topical treatments for psoriasis. Dermatol Online J. 2003;9:2
  8. Linden KG, Weinstein GD. Psoriasis: current perspectives with an emphasis on treatment. Am J Med. 1999;107:595–605
  9. Long CC, Finlay AY. The finger-tip unit—a new practical measure. Clin Exp Dermatol. 1991;16:444–447
  10. Brown KK, Rehmus WE, Kimball AB. Determining the relative importance of patient motivations for nonadherence to topical corticosteroid therapy in psoriasis. J Am Acad Dermatol. 2006;55:607–613
  11. Feldman SR, Horn EJ, Balkrishnan R, Basra MK, Finlay AY, McCoy D, et al. Psoriasis: improving adherence to topical therapy. J Am Acad Dermatol. 2008;59:1009–1016
  12. Cornell RC, Stoughton RB. Correlation of the vasoconstriction assay and clinical activity in psoriasis. Arch Dermatol. 1985;121:63–67
  13. Bernhard J, Whitmore C, Guzzo C, Kantor I, Kalb RE, Ellis C, et al. Evaluation of halobetasol propionate ointment in the treatment of plaque psoriasis: report on two double-blind, vehicle-controlled studies. J Am Acad Dermatol. 1991;25:1170–1174
  14. Lebwohl M, Sherer D, Washenik K, Krueger GG, Menter A, Koo J, et al. A randomized, double-blind, placebo-controlled study of clobetasol propionate 0.05% foam in the treatment of nonscalp psoriasis. Int J Dermatol. 2002;41:269–274
  15. Gottlieb AB, Ford RO, Spellman MC. The efficacy and tolerability of clobetasol propionate foam 0.05% in the treatment of mild to moderate plaque-type psoriasis of nonscalp regions. J Cutan Med Surg. 2003;7:185–192
  16. Olsen EA, Cram DL, Ellis CN, Hickman JG, Jacobson C, Jenkins EE, et al. A double-blind, vehicle-controlled study of clobetasol propionate 0.05% (Temovate) scalp application in the treatment of moderate to severe scalp psoriasis. J Am Acad Dermatol. 1991;24:443–447
  17. Savin RC. Desoximetasone—a new topical corticosteroid: short- and long-term experiences. Cutis. 1978;21:403–407
  18. Lepaw MI. Double-blind comparison of halcinonide solution and placebo control in treatment of psoriasis of the scalp. Cutis. 1978;21:571–573
  19. Olsen EA. Efficacy and safety of fluticasone propionate 0.005% ointment in the treatment of psoriasis. Cutis. 1996;57:57–61
  20. Franz TJ, Parsell DA, Halualani RM, Hannigan JF, Kalbach JP, Harkonen WS. Betamethasone valerate foam 0.12%: a novel vehicle with enhanced delivery and efficacy. Int J Dermatol. 1999;38:628–632
  21. Stein LF, Sherr A, Solodkina G, Gottlieb AB, Chaudhari U. Betamethasone valerate foam for treatment of nonscalp psoriasis. J Cutan Med Surg. 2001;5:303–307
  22. Sears H, Bailer JW, Yeadon A. A double-blind, randomized placebo-controlled evaluation of the efficacy and safety of hydrocortisone buteprate 0.1% cream in the treatment of psoriasis. Adv Ther. 1997;14:140–149
  23. Pauporte M, Maibach H, Lowe N, Pugliese M, Friedman DJ, Mendelsohn H, et al. Fluocinolone acetonide topical oil for scalp psoriasis. J Dermatolog Treat. 2004;15:360–364
  24. Mason J, Mason AR, Cork MJ. Topical preparations for the treatment of psoriasis: a systematic review. Br J Dermatol. 2002;146:351–364
  25. Katz HI, Prawer SE, Medansky RS, Krueger GG, Mooney JJ, Jones ML, et al. Intermittent corticosteroid maintenance treatment of psoriasis: a double-blind multicenter trial of augmented betamethasone dipropionate ointment in a pulse dose treatment regimen. Dermatologica. 1991;183:269–274
  26. Miller JJ, Roling D, Margolis D, Guzzo C. Failure to demonstrate therapeutic tachyphylaxis to topically applied steroids in patients with psoriasis. J Am Acad Dermatol. 1999;41:546–549
  27. Katz HI, Hien NT, Prawer SE, Mastbaum LI, Mooney JJ, Samson CR. Superpotent topical steroid treatment of psoriasis vulgaris—clinical efficacy and adrenal function. J Am Acad Dermatol. 1987;16:804–811
  28. Eichenfield LF, Basu S, Calvarese B, Trancik RJ. Effect of desonide hydrogel 0.05% on the hypothalamic-pituitary-adrenal axis in pediatric subjects with moderate to severe atopic dermatitis. Pediatr Dermatol. 2007;24:289–295
  29. Morimoto S, Kumahara Y. A patient with psoriasis cured by 1 alpha-hydroxyvitamin D3. Med J Osaka Univ. 1985;35:51–54
  30. Highton A, Quell J. Calcipotriene ointment 0.005% for psoriasis: a safety and efficacy study. Calcipotriene Study Group. J Am Acad Dermatol. 1995;32:67–72
  31. Dubertret L, Wallach D, Souteyrand P, Perussel M, Kalis B, Meynadier J, et al. Efficacy and safety of calcipotriol (MC 903) ointment in psoriasis vulgaris. A randomized, double-blind, right/left comparative, vehicle-controlled study. J Am Acad Dermatol. 1992;27:983–988
  32. Green C, Ganpule M, Harris D, Kavanagh G, Kennedy C, Mallett R, et al. Comparative effects of calcipotriol (MC903) solution and placebo (vehicle of MC903) in the treatment of psoriasis of the scalp. Br J Dermatol. 1994;130:483–487
  33. Hecker D, Lebwohl M. Topical calcipotriene in combination with UVB phototherapy for psoriasis. Int J Dermatol. 1997;36:302–303
  34. McKenna KE, Stern RS. Photosensitivity associated with combined UV-B and calcipotriene therapy. Arch Dermatol. 1995;131:1305–1307
  35. Oranje AP, Marcoux D, Svensson A, Prendiville J, Krafchik B, Toole J, et al. Topical calcipotriol in childhood psoriasis. J Am Acad Dermatol. 1997;36:203–208
  36. Darley CR, Cunliffe WJ, Green CM, Hutchinson PE, Klaber MR, Downes N. Safety and efficacy of calcipotriol ointment (Dovonex) in treating children with psoriasis vulgaris. Br J Dermatol. 1996;135:390–393
  37. Kaufmann R, Bibby AJ, Bissonnette R, Cambazard F, Chu AC, Decroix J, et al. A new calcipotriol/betamethasone dipropionate formulation (Daivobet) is an effective once-daily treatment for psoriasis vulgaris. Dermatology. 2002;205:389–393
  38. Kragballe K, Austad J, Barnes L, Bibby A, de la Brassinne M, Cambazard F, et al. A 52-week randomized safety study of a calcipotriol/betamethasone dipropionate two-compound product (Dovobet/Daivobet/Taclonex) in the treatment of psoriasis vulgaris. Br J Dermatol. 2006;154:1155–1160
  39. Weinstein GD, Krueger GG, Lowe NJ, Duvic M, Friedman DJ, Jegasothy BV, et al. Tazarotene gel, a new retinoid, for topical therapy of psoriasis: vehicle-controlled study of safety, efficacy, and duration of therapeutic effect. J Am Acad Dermatol. 1997;37:85–92
  40. Weinstein GD, Koo JY, Krueger GG, Lebwohl MG, Lowe NJ, Menter MA, et al. Tazarotene cream in the treatment of psoriasis: two multicenter, double-blind, randomized, vehicle-controlled studies of the safety and efficacy of tazarotene creams 0.05% and 0.1% applied once daily for 12 weeks. J Am Acad Dermatol. 2003;48:760–767
  41. Veraldi S, Caputo R, Pacifico A, Peris K, Soda R, Chimenti S. Short contact therapy with tazarotene in psoriasis vulgaris. Dermatology. 2006;212:235–237
  42. Koo JY, Lowe NJ, Lew-Kaya DA, Vasilopoulos AI, Lue JC, Sefton J, et al. Tazarotene plus UVB phototherapy in the treatment of psoriasis. J Am Acad Dermatol. 2000;43:821–828
  43. Lebwohl M, Freeman AK, Chapman MS, Feldman SR, Hartle JE, Henning A. Tacrolimus ointment is effective for facial and intertriginous psoriasis. J Am Acad Dermatol. 2004;51:723–730
  44. Gribetz C, Ling M, Lebwohl M, Pariser D, Draelos Z, Gottlieb AB, et al. Pimecrolimus cream 1% in the treatment of intertriginous psoriasis: a double-blind, randomized study. J Am Acad Dermatol. 2004;51:731–738
  45. Tacrolimus [package insert]. Available at: http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.Overview&DrugName=PROGRAFAccessed July 30, 2008
  46. Pimecrolimus [package insert]. Available at: http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.DrugDetailsAccessed July 30, 2008
  47. Berger TG, Duvic M, Van Voorhees AS, VanBeek MJ, Frieden IJ. The use of topical calcineurin inhibitors in dermatology: safety concerns. Report of the American Academy of Dermatology Association Task Force. J Am Acad Dermatol. 2006;54:818–823
  48. Ring J, Barker J, Behrendt H, Braathen L, Darsow U, Dubertret L, et al. Review of the potential photo-cocarcinogenicity of topical calcineurin inhibitors: position statement of the European Dermatology Forum. J Eur Acad Dermatol Venereol. 2005;19:663–671
  49. Margolis DJ, Hoffstad O, Bilker W. Lack of association between exposure to topical calcineurin inhibitors and skin cancer in adults. Dermatology. 2007;214:289–295
  50. Syed TA, Ahmad SA, Holt AH, Ahmad SH, Afzal M. Management of psoriasis with Aloe vera extract in a hydrophilic cream: a placebo-controlled, double-blind study. Trop Med Int Health. 1996;1:505–509
  51. Paulsen E, Korsholm L, Brandrup F. A double-blind, placebo-controlled study of a commercial Aloe vera gel in the treatment of slight to moderate psoriasis vulgaris. J Eur Acad Dermatol Venereol. 2005;19:326–331
  52. Lebwohl M. The role of salicylic acid in the treatment of psoriasis. Int J Dermatol. 1999;38:16–24
  53. McGill A, Frank A, Emmett N, Turnbull DM, Birch-Machin MA, Reynolds NJ. The anti-psoriatic drug anthralin accumulates in keratinocyte mitochondria, dissipates mitochondrial membrane potential, and induces apoptosis through a pathway dependent on respiratory competent mitochondria. FASEB J. 2005;19:1012–1014
  54. Jekler J, Swanbeck G. One-minute dithranol therapy in psoriasis: a placebo-controlled paired comparative study. Acta Derm Venereol. 1992;72:449–450
  55. Grattan C, Hallam F, Whitefield M. A new aqueous dithranol gel for psoriasis: comparison with placebo and calcipotriol ointment. J Dermatol Treat. 1997;8:11–15
  56. Kanzler MH, Gorsulowsky DC. Efficacy of topical 5% liquor carbonis detergens vs. its emollient base in the treatment of psoriasis. Br J Dermatol. 1993;129:310–314
  57. Goodfield M, Kownacki S, Berth-Jones J. Double-blind, randomised, multicentre, parallel group study comparing a 1% coal tar preparation (Exorex) with a 5% coal tar preparation (Alphosyl) in chronic plaque psoriasis. J Dermatolog Treat. 2004;15:14–22
  58. Hannuksela-Svahn A, Pukkala E, Laara E, Poikolainen K, Karvonen J. Psoriasis, its treatment, and cancer in a cohort of Finnish patients. J Invest Dermatol. 2000;114:587–590
  59. Maughan WZ, Muller SA, Perry HO, Pittelkow MR, O'Brien PC. Incidence of skin cancers in patients with atopic dermatitis treated with coal tar. A 25-year follow-up study. J Am Acad Dermatol. 1980;3:612–615
  60. Stern RS, Zierler S, Parrish JA. Skin carcinoma in patients with psoriasis treated with topical tar and artificial ultraviolet radiation. Lancet. 1980;1:732–735
  61. Franssen ME, van der Wilt GJ, de Jong PC, Bos RP, Arnold WP. A retrospective study of the teratogenicity of dermatological coal tar products. Acta Derm Venereol. 1999;79:390–391
  62. Lam J, Polifka JE, Dohil MA. Safety of dermatologic drugs used in pregnant patients with psoriasis and other inflammatory skin diseases. J Am Acad Dermatol. 2008;59:295–315
  63. Koo J, Cuffie CA, Tanner DJ, Bressinck R, Cornell RC, DeVillez RL, et al. Mometasone furoate 0.1%-salicylic acid 5% ointment versus mometasone furoate 0.1% ointment in the treatment of moderate-to-severe psoriasis: a multicenter study. Clin Ther. 1998;20:283–291
  64. Kragballe K, Barnes L, Hamberg KJ, Hutchinson P, Murphy F, Moller S, et al. Calcipotriol cream with or without concurrent topical corticosteroid in psoriasis: tolerability and efficacy. Br J Dermatol. 1998;139:649–654
  65. Austad J, Bjerke JR, Gjertsen BT, Helland S, Livden JK, Morken T, et al. Clobetasol propionate followed by calcipotriol is superior to calcipotriol alone in topical treatment of psoriasis. J Eur Acad Dermatol Venereol. 1998;11:19–24
  66. Papp KA, Guenther L, Boyden B, Larsen FG, Harvima RJ, Guilhou JJ, et al. Early onset of action and efficacy of a combination of calcipotriene and betamethasone dipropionate in the treatment of psoriasis. J Am Acad Dermatol. 2003;48:48–54
  67. Lebwohl MG, Breneman DL, Goffe BS, Grossman JR, Ling MR, Milbauer J, et al. Tazarotene 0.1% gel plus corticosteroid cream in the treatment of plaque psoriasis. J Am Acad Dermatol. 1998;39:590–596
  68. Koo JY, Martin D. Investigator-masked comparison of tazarotene gel q.d. plus mometasone furoate cream q.d. vs. mometasone furoate cream b.i.d. in the treatment of plaque psoriasis. Int J Dermatol. 2001;40:210–212
  69. Lebwohl M, Lombardi K, Tan MH. Duration of improvement in psoriasis after treatment with tazarotene 0.1% gel plus clobetasol propionate 0.05% ointment: comparison of maintenance treatments. Int J Dermatol. 2001;40:64–66
  70. Kaidbey K, Kopper SC, Sefton J, Gibson JR. A pilot study to determine the effect of tazarotene gel 0.1% on steroid-induced epidermal atrophy. Int J Dermatol. 2001;40:468–471
  71. Carroll CL, Clarke J, Camacho F, Balkrishnan R, Feldman SR. Topical tacrolimus ointment combined with 6% salicylic acid gel for plaque psoriasis treatment. Arch Dermatol. 2005;141:43–46
  72. Kragballe K, Gjertsen BT, De Hoop D, Karlsmark T, van de Kerkhof PC, Larko O, et al. Double-blind, right/left comparison of calcipotriol and betamethasone valerate in treatment of psoriasis vulgaris. Lancet. 1991;337:193–196
  73. Camarasa JM, Ortonne JP, Dubertret L. Calcitriol shows greater persistence of treatment effect than betamethasone dipropionate in topical psoriasis therapy. J Dermatolog Treat. 2003;14:8–13
  74. Ashcroft DM, Po AL, Williams HC, Griffiths CE. Systematic review of comparative efficacy and tolerability of calcipotriol in treating chronic plaque psoriasis. BMJ. 2000;320:963–967
  75. Lebwohl M, Ast E, Callen JP, Cullen SI, Hong SR, Kulp-Shorten CL, et al. Once-daily tazarotene gel versus twice-daily fluocinonide cream in the treatment of plaque psoriasis. J Am Acad Dermatol. 1998;38:705–711
  76. Guenther LC, Poulin YP, Pariser DM. A comparison of tazarotene 0.1% gel once daily plus mometasone furoate 0.1% cream once daily versus calcipotriene 0.005% ointment twice daily in the treatment of plaque psoriasis. Clin Ther. 2000;22:1225–1238
  77. Liao YH, Chiu HC, Tseng YS, Tsai TF. Comparison of cutaneous tolerance and efficacy of calcitriol 3 microg g(-1) ointment and tacrolimus 0.3 mg g(-1) ointment in chronic plaque psoriasis involving facial or genitofemoral areas: a double-blind, randomized controlled trial. Br J Dermatol. 2007;157:1005–1012
  78. Kreuter A, Sommer A, Hyun J, Brautigam M, Brockmeyer NH, Altmeyer P, et al. 1% pimecrolimus, 0.005% calcipotriol, and 0.1% betamethasone in the treatment of intertriginous psoriasis: a double-blind, randomized controlled study. Arch Dermatol. 2006;142:1138–1143
  79. Menter Kamili. Topical treatment of psoriasis. In:  Yawalkar N editors. Current problems in dermatology. Basel, Switzerland: S. Karger AG; 2009;

 Funding sources: None.

 The authors' conflict of interest/disclosure statements appear at the end of the article.

PII: S0190-9622(09)00012-7

doi: 10.1016/j.jaad.2008.12.032

Journal of the American Academy of Dermatology
Volume 60, Issue 4 , Pages 643-659 , April 2009