General practice recommendations for the topical treatment of psoriasis: a modified-Delphi approach

Question 1: Which patients are candidates for topical psoriasis treatment?

1. Topical treatment (selected according to specific body sites and the clinical phenotype of disease) is generally a first-line treatment approach in all patients treated by GPs.

2. Patients with moderate or severe disease receiving systemic therapies or phototherapy may benefit from concomitant topical therapies because residual disease can cause considerable impact on health-related quality of life (HRQoL).

Question 2: What factors inform the selection of one topical treatment over another for mild-to-moderate psoriasis?

1. Choice of topical agent should be based on the site (Table 3 and Table 4), extent and features of psoriasis, such as level of hyperkeratosis, redness, thickness, presence of inflammation, severity of itch, and pain.

2. Practical factors should be considered, for example, formulation (Table 3), and discussed with your patient to ensure suitability.

3. If prescribing corticosteroids, the right potency for the area affected should be chosen (see Table 4 for guidance).

4. There are systemic safety issues with use of potent corticosteroids on large skin areas that are more pronounced if the area is occluded.

5. Initial use of low-potency (for example, hydrocortisone cream 1%) or underdosed topical corticosteroids should be avoided as treatment is unlikely to be successful and this could adversely affect adherence.

6. Special consideration needs to be given to certain patient subpopulations, that is, children, pregnant women, and breastfeeding mothers. Prescribing information should be checked before using topical treatments for them (see Supplementary Table S2 for further guidance).

Figure 1 is provided as guidance to aid treatment decision making. It highlights stepwise-treatment decision drivers based on disease location, severity and symptoms, and other considerations, such as presence of itch or patient subpopulations. Disease severity is generally assessed using: Physician Global Assessment (PGA); Body Surface Area (BSA); or Psoriasis Area and Severity Index (PASI), which rate the quality (redness, thickness, and scaliness) and/or surface area of the plaques. For practical tips on estimating BSA see Supplementary Table S2, section 1. Potent and super-potent topical corticosteroids are effective, but their long-term use is limited by concerns about side effects.¹ For patients receiving topical corticosteroids, particularly the highest potency, it is recommended that disease severity is monitored and an alternative topical treatment is switched to (for example, calcipotriene plus betamethasone dipropionate [Cal/BD] fixed-dose combination) after 2 weeks (if no response) and a maximum of 4 weeks. Calcipotriol and calcipotriol or Cal/BD are marketed by LEO Pharma, the sponsor of this work, under the tradenames (UK) Dovonex (calcipotriol ointment), Enstilar (Cal/BD foam), and Dovobet (Cal/BD gel and ointment). The fixed-dose Cal/BD aerosol foam is preferable because it leads to higher skin penetration of the active ingredients and has superior efficacy compared with ointment or gel formulation^15,16 and monotherapies.⁴

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Figure 1. Topical treatment algorithm

Emollients play a basic role in the topical treatment of psoriasis,¹⁷ and there is some evidence of improvement of psoriasis with keratolytic compounds used as monotherapy or in combination with other therapies, either during or before the use of active drugs.¹⁸

It is believed there is currently no ‘one-size-fits-all’ treatment pathway for patients with mild-to-moderate psoriasis and no preferred sequence of treatments. While treatment decision making should be individualised to the patient, choice of treatment and formulation can be based on an individual’s key symptom(s). Table 5 has been designed to support treatment decision making based on symptoms of psoriasis and should be used in conjunction with Tables 3 and 4 to factor in the location of the disease.

Question 3: What outcomes should a physician or patient expect from topical treatment and within what time frame?

1. Satisfactory improvement (for example, changes in redness, scaling, thickness or plaques, and the size of the area involved) should be observed by the patient within 2 weeks. For some symptoms, such as itch, improvement may be felt as early as a few days.^19,20 At around 4 weeks, a marked improvement (for example, clear or almost clear outcome) should be expected, even if further improvement can still be seen after 4 weeks. If there is no clinically relevant improvement after 4 weeks, adherence should be assessed (including consumption) and treatment switched if the patient is fully adherent (Table 4).

   • If residual redness is seen, without plaque elevation or desquamation, treatment can be tapered.

2. Patient expectations should be carefully managed to ensure they are realistic about:

   • how well the medication may work;

   • how soon they should expect to see an improvement in symptoms;

   • side effects that may occur; and

   • any additional treatment that may be required beyond 4–8 weeks.

Question 4: How long should topical treatments be used for?

Table 4 details the suggested length of treatment based on the expected time frame to achieving outcome (from expert experience).

1. A topical treatment should be used (except potent and super-potent corticosteroids) at the minimum effective frequency for as long as it provides continuous improvement or disease control, and is safe and well tolerated with minimal side effects.

2. Regardless of plaque location, potent corticosteroids should not be used for longer than 6 weeks without interruption. If remission is not achieved in this time frame, the patient should be referred to a dermatologist, as the diagnosis may need to be reconsidered and/or systemic treatment options considered. In the meantime, less potent corticosteroids or alternative topical drugs can be used. If necessary, after an interruption of at least 6–8 weeks, treatment with potent corticosteroids can be recommenced. This statement is based on clinical experience of dermatologists, as there is no published consistent clinical and experimental evidence to support this statement; the potency of different corticosteroids is provided in Supplementary Table S3.

3. Super-potent steroids, such as clobetasol, should not be used daily for >2 weeks.

4. Combination therapies containing topical corticosteroids and salicylic acid (if not contraindicated) can be used for as long as the strength of the corticosteroid component allows, provided that scaling has been significantly reduced.

5. If long-term topical treatment of psoriasis is required, vitamin D3 analogues and their combinations are recommended.

6. Psoriasis should be treated to minimum disease activity regardless of the site of the disease.

The frequency of flares, if ascertainable, can be used to inform whether a patient requires long-term management with topicals. There are different approaches to treatment regimens; for example, option one: used daily for a number of weeks until clear or almost clear and then switched to ‘as needed’, during which time the patient can retreat when needed. Option 2: treated daily for a number of weeks, followed by gradual tapering; for example, every second day for 2 weeks, then twice a week for 2 weeks, once a week for 2 weeks, and then the treatment is paused. If, however, mild psoriasis activity increases at any stage, tapering should be ceased and an appropriate interval should be established at which the disease is at an acceptable level of activity.

In addition to the ‘as needed’ and ‘tapering’ approaches detailed above, maintenance treatment with topical therapies, using reduced potency and/or frequency, can be considered. For example, consider the option of applying topical therapies on two specified days of the week, as agreed in collaboration with the patient.

Question 5: What are the drivers of treatment switching?

1. Consider switching topical treatments if:

   • poor or no improvement is seen within 4 weeks;

   • patient is dissatisfied and wishes to explore other options;

   • patient has continued psoriasis-related impairment of HRQoL;

   • the treatment is poorly tolerated;

   • patient’s lifestyle or circumstances change; and/or

   • newer interventions with better benefit or risk profiles become available.

2. If poor adherence is suspected and ascertained, the patient should be worked with to try to improve it before switching, unless a treatment-specific factor is the reason for poor adherence.

Question 6: What features of a topical treatment maximise adherence?

a. The following features of a topical treatment maximise adherence (Table 1 and Table 2):

• Clinical effectiveness

  • The appearance of plaques should be examined to assess disease severity, which is defined as severe (thick and scaly with a lot of erythema), moderate (moderate in its scaling, thickness, and redness), mild or almost clear (possibly still pink and barely perceptible without real scaling), and clear (completely clear without any erythema), as well as improvement in other symptoms, such as itching.⁷

• Fast onset of action

  • Tell the patient that the effect can be expected within 1–2 weeks of treatment and that they must remain patient if it takes longer (that is, up to 6–8 weeks of treatment).

• Tolerable side effects

  • Treatments that minimise tolerability problems (for example, burning and itching) and do not cause obvious skin atrophy are preferred.

• Cosmetically acceptable

  • Formulation, areas of application, and patient preference should be considered (Table 2).

• Practicability

  • Some patients may prefer the simplicity and practicability of a fixed-dose combination regimen, which allows reduced frequency of application versus monotherapies.

  • Choose an easy treatment regimen that is also preferred by the patient, for example, once-daily application.

Corticosteroids (alone or in combination) are often the topical treatment of choice, but ‘corticosteroid-phobia’, which has been described as an irrational fear towards steroids, is a contributing factor in treatment non-adherence.²¹ Rather than prescribe other (often less effective) steroid-free treatments, patients should be reassured that the safety of modern topical corticosteroids is well established when used appropriately.²¹

Question 7: What simple instructions can be shared with patients regarding the use of topical treatments to maximise efficacy and adherence?

1. Ensure you have been as specific as possible. Written instruction should contain: name of product, dosing, frequency, body location, and length of treatment.

2. Available written instructions should be used, for example, a compact pocket card, from patient associations or other trusted sources, which you have reviewed and are in line with your recommendations.

3. Where appropriate, family members should be involved to support the patient with their treatment. This is particularly relevant if the disease is located on the scalp or back, or if the patient has reduced mobility or severe obesity.

For further guidance on optimising doctor–patient communication, see Supplementary Table S4.