FROM THE ACADEMY 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,a Neil J. Korman, MD, PhD,b Craig A. Elmets, MD,c StevenR.Feldman,MD,PhD,d Joel M. Gelfand, MD, MSCE,e Kenneth B. Gordon, MD,f Alice Gottlieb, MD, PhD,g John Y. M. Koo, MD,h Mark Lebwohl, MD,i HenryW.Lim,MD,j Abby S. Van Voorhees, MD,k Karl R. Beutner, MD, PhD,h,l and Reva Bhushan, PhDm Dallas, Texas; Cleveland, Ohio; Birmingham, Alabama; Winston-Salem, North Carolina; Philadelphia, Pennsylvania; Chicago and Schaumburg, Illinois; Boston, Massachusetts; San Francisco and Palo Alto, California; New York, New York; and Detroit, Michigan Psoriasis is a common, chronic, inflammatory, multi-system disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In this third of 6 sections of the guidelines of care for psoriasis, we discuss the use of topical medications for the treatment of psoriasis. The majority of patients with psoriasis have limited disease (\5% body surface area involvement) and can be treated with topical agents, which generally provide a high efficacy-to-safety ratio. Topical agents may also be used adjunctively for patients with more extensive psoriasis undergoing therapy with either ultraviolet light, systemic or biologic medications. However, the use of topical agents as monotherapy in the setting of extensive disease or in the setting of limited, but recalcitrant, disease is not routinely recommended. Treatment should be tailored to meet individual patients’ needs. We will discuss the efficacy and safety of as well as offer recommendations for the use of topical corticosteroids, vitamin D analogues, tazarotene, tacrolimus, pimecrolimus, emollients, salicylic acid, anthralin, coal tar, as well as combination therapy. ( J Am Acad Dermatol 2009;60:643-59.) DISCLAIMER Adherence to these guidelines will not ensure Abbreviations used: successful treatment in every situation. Furthermore, AAD: American Academy of Dermatology HPA: hypothalamic-pituitary-adrenal (axis) these guidelines should not be deemed inclusive of PASI: Psoriasis Area and Severity Index all proper methods of care nor exclusive of other PGA: physician’s global assessment methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific therapy must be made SCOPE by the physician and the patient in light of all the This third section covers the management and circumstances presented by the individual patient. treatment of psoriasis with topical therapies. From the Baylor University Medical Center, Dallasa; Department of Department of Dermatology, Henry Ford Hospital, Detroitj; Dermatology, Murdough Family Center for Psoriasis, Depart- Department of Dermatology, University of Pennsylvania, Phil- ment of Dermatology, University Hospitals Case Medical Cen- adelphiak; Anacor Pharmaceuticals, Inc, Palo Altol; and Amer- ter, Clevelandb; Department of Dermatology, University of ican Academy of Dermatology.m Alabama at Birminghamc; Department of Dermatology, Wake Funding sources: None. Forest University School of Medicine, Winston-Salemd; Depart- The authors’ conflict of interest/disclosure statements appear at ment of Dermatology and Center for Clinical Epidemiology and the end of the article. Biostatistics, University of Pennsylvania, Philadelphiae; Division Reprint requests: Reva Bhushan, PhD, 930 E Woodfield Rd, of Dermatology, Evanston Northwestern Healthcare and De- Schaumburg, IL 60173. E-mail: [email protected]. partment of Dermatology, Northwestern University, Feinberg Published online February 17, 2009. School of Medicine, Chicagof; Tufts Medical Center, Tufts 0190-9622/$36.00 University School of Medicine, Bostong; Department of Derma- ª 2009 by the American Academy of Dermatology, Inc. tology, University of CaliforniaeSan Franciscoh; Department of doi:10.1016/j.jaad.2008.12.032 Dermatology, Mount Sinai School of Medicine, New Yorki; 643 644 Menter et al JAM ACAD DERMATOL APRIL 2009 METHOD agents which generally provide both high efficacy A work group of recognized psoriasis experts was and safety. Topical agents are also used adjunc- convened to determine the audience for and scope tively for resistant lesions in patients with more of the guideline and to identify clinical questions to extensive psoriasis who are being concurrently structure the primary issues in diagnosis and treated with either ultraviolet light or systemic management discussed in American Academy of medications. However, the use of topical agents Dermatology (AAD) psoriasis guidelines Sections as monotherapy in the setting of extensive disease 1 and 2.1,2 Work group members completed a or in the setting of limited, but recalcitrant disease is disclosure of commercial support. not routinely recommended. Treatment should be An evidence-based model was used and evidence tailored to meet individual patients’ needs. These was obtained using a search of the MEDLINE data- needs vary depending on body location, character- base spanning the years 1960 through 2008. istics of the psoriasis being treated including lesion The available evidence was evaluated using a uni- thickness, degree of erythema and amount of fied system called the Strength of Recommendation scaling, as well as patient preferences. It is impor- Taxonomy developed by editors of the US family tant to match patient expectations with practical medicine and primary care journals (ie, American considerations. Patients who wish for lifetime clear- Family Physician, Family Medicine, Journal of Family ance with no evident lesions will inevitably be Practice,andBMJ USA). This strategy was supported by disappointed with topical therapy because of the a decision of the Clinical Guidelines Task Force in 2005 need for a continuous intense topical regimen that with some minor modifications for a consistent ap- will be very difficult to carry out and maintain. proach to rating the strength of the evidence of Some patients may desire to be free from pruritus scientific studies.3 Evidence was graded using a 3- and to have a diminution in their most visible point scale based on the quality of methodology as lesions. Others may prefer only intermittent treat- follows: ment with little interest in spending considerable I. Good-quality patient-oriented evidence time to care for their psoriasis. It is important to II. Limited-quality patient-oriented evidence ascertain each patient’s goals and then to develop a III. Other evidence including consensus guidelines, strategy to help fulfill his or her expectations while opinion, or case studies also being practical and realistic. The choice of vehicle can significantly alter the Clinical recommendations were developed on the use and penetration of the medication and therefore best available evidence tabled in the guideline. alter the efficacy. Vehicle types are numerous and These are ranked as follows: may include ointments, creams, solutions, gels, A. Recommendation based on consistent and good- foams, tape, sprays, shampoos, oils, and lotions. quality patient-oriented evidence Different vehicles are indicated for different body B. Recommendation based on inconsistent or lim- sites. The optimal choice is generally the vehicle the ited-quality patient-oriented evidence individual patient will most likely use. For example, C. Recommendation based on consensus, opinion, hair-bearing areas including the scalp can be treated or case studies with solutions, foams, shampoos, sprays, oils, gels, In those situations where documented evidence- or other vehicles, with individual patients having based data are not available, we have utilized expert different preferences among these options. Some opinion to generate our clinical recommendations. patients may prefer a less greasy preparation, per- Prior guidelines on psoriasis were also evaluated.4,5 haps a cream for daytime use and may be willing to This guideline has been developed in accordance use an ointment, which is more effective but less with the AAD/AAD Association ‘‘Administrative cosmetically appealing, at night. Cultural prefer- Regulations for Evidence-based Clinical Practice ences may also make one vehicle preferred over Guidelines,’’ which include the opportunity for re- others for a given site. Occlusion of topical medica- view and comment by the entire AAD membership tions can also alter the penetration, thereby varying and final review and approval by the AAD Board of the effectiveness. The observation that flurandreno- Directors. lide 0.1%, which is a class 5 topical steroid when used in the cream or lotion formulation, functions as a class 1 topical steroid when used as a tape and has a GENERAL PRINCIPLES higher efficacy than the class 1 steroid diflorasone Approximately 80% of patients affected with diacetate ointment in the treatment of psoriasis6 psoriasis have mild to moderate disease. The ma- serves as a strong reminder of the impact of jority of these patients can be treated with topical occlusion. JAM ACAD DERMATOL Menter et al 645 VOLUME 60, NUMBER 4 Table I. Use of topical agents: The fingertip unit and how to assess quantity of topical agents needed to cover a given body surface area79 No. of Approximate fingertip body surface Area to be treated units area (%) Scalp 3 6 Face and neck 2.5 5 One hand (front and back) 12 including fingers One entire arm including 48 Fig 1. Use of topical agents—the fingertip unit and