TOPICAL TREATMENTS FOR PSORIASIS
What are the aims of this leaflet?
This leaflet has been written to help provide information about the topical treatment of psoriasis. It explains what topical treatment is, how it is used and how to find out more about it.
What are topical treatments?
A topical treatment is something that is applied directly to the skin or body surface. The commonest examples are lotions, creams, ointments, gels and shampoos. Most people with mild psoriasis are able to manage their skin complaint with topical treatment. Moderate or severe psoriasis usually needs additional therapy such as ultraviolet or oral (by mouth) medication. See patient information leaflet “Treatments for moderate or severe psoriasis”.
What is psoriasis?
Psoriasis is a common inflammatory skin disease affecting 2% of the population. It occurs equally in men and women, can appear at any age, and tends to come and go unpredictably. It is not infectious, therefore you cannot catch psoriasis from someone else. It does not scar the skin although sometimes it can cause a temporary increase or reduction in skin pigmentation. Although psoriasis is a long-term condition there are many effective treatments available to keep it under good control.
Psoriasis can affect the nails and the joints as well as the skin. About half of people with psoriasis have psoriasis affecting the nails. For people with moderate to severe psoriasis about one in three will develop psoriatic arthritis at some time. Psoriatic arthritis produces swelling and stiffness in the joints or stiffness in the lower back and should be managed by a rheumatologist who works closely with your dermatologist and/or your GP.
Psoriasis, particularly moderate to severe psoriasis, is associated with an increased risk of anxiety and depression. Moderate to severe psoriasis increases the risk of heart disease and stroke and treatment of psoriasis may reduce this risk. Psoriasis can also be associated with an increased risk of harmful use of alcohol and with diabetes and obesity.
Can psoriasis be cured?
Unfortunately there is no cure for psoriasis yet. However, in most cases the condition can be improved, and sometimes cleared, by regular use of treatment. Psoriasis usually comes back (relapses) if treatment is stopped. There is no evidence that any treatment alters the future severity of psoriasis. Delaying treatment or using treatment early does not affect the future outcome (prognosis) of psoriasis.
What are the main topical treatments used for psoriasis?
The aims of topical psoriasis treatment are to remove excess scaly skin and calm the underlying inflammation. This will improve the appearance and help the skin feel more comfortable and less itchy. Different treatments are often used at different body sites and for some areas such as the scalp, a combination of treatments are needed to get the best results. Treatments for psoriasis include the following:
Emollients (moisturisers) work by moisturising dry skin, reducing scaling and relieving itching. They soften cracked areas and help other topical treatment get through the skin and work more effectively. They can also be used instead of soap for washing and cleansing washing. It is usually advised that they are applied about 30 minutes before other psoriasis treatments such as steroids (see below). Very mild psoriasis may settle with emollients alone. Emollients can be applied as often as needed until the skin is no longer dry.
Paraffin-based emollients carry a fire risk. While emollients are in contact with your medical dressing or clothing, we advise that you do not:
use naked flames
get near people who are smoking or using naked flames
go near anything that may cause flames
As these emollients also soak in fabrics, it is important that you change your clothing and bedding regularly.
CAUTION: This leaflet mentions ‘emollients’ (moisturisers). Emollients, creams, lotions and ointments contain oils which can catch fire. When emollient products get in contact with dressings, clothing, bed linen or hair, there is a danger that a naked flame or cigarette smoking could cause these to catch fire. To reduce the fire risk, patients using skincare or haircare products are advised to be very careful near naked flames to reduce the risk of clothing, hair or bedding catching fire. In particular smoking cigarettes should be avoided and being near people who are smoking or using naked flames, especially in bed. Candles may also risk fire. It is advisable to wash clothing daily which is in contact with emollients and bed linen regularly.
Emollients containing salicylic acid in low concentration can help reduce excessive scaling but may sometimes irritate the surrounding skin.
Topical steroids work by reducing skin inflammation. They are available in different strengths (mild, moderate, potent (strong) and super-potent (extra strong). Mild topical steroids can be helpful on the face or in the skin folds (e.g. under the arms) for short courses. Stronger topical steroids may be useful on thickened plaques of psoriasis such as the palms and soles. If they are used on the same area of skin long-term, there is a risk of skin thinning (skin atrophy), so ongoing prescriptions should be monitored by your doctor.
There is a tendency for psoriasis to return quickly when topical steroid treatment is stopped abruptly especially if stronger steroids have been used.
Tar preparations have been used to treat psoriasis for many years. They help reduce scaling and slow the skin overgrowth that occurs in psoriasis. Tar preparations include bath oils, creams, ointment and shampoos. Coal tar has a distinctive smell that some people dislike and tar preparations can be messy and stain clothing so they are less popular nowadays.
Dithranol is a useful traditional treatment for stubborn plaques of psoriasis on ‘non-delicate’ skin such as elbows and knees. Nowadays, it is usually given as ‘short contact therapy’ which is done at home. This involves applying a cream containing dithranol to affected areas of skin for increasing time periods ranging from 10 minutes to an hour according to the prescriber’s instructions, before rinsing with warm water. The creams are available in different strengths, and the strength used or length of time it is applied can be gradually increased during a course of treatment.
Dithranol stains clothes, so it is advisable to wear old clothes whilst the treatment is on the skin. It can also stain the bath or shower so these should be cleaned immediately after use. Treatment is usually carried out once a day. As the psoriasis clears, the treated areas flatten and darken with a brownish stain that gradually fades after treatment is completed. Occasionally dithranol causes irritation of the treated area and surrounding skin and treatment needs to be stopped or a weaker preparation used. Dithranol is not usually applied to the face and the body folds because it is too irritating at these sites.
Vitamin D analogues (calcipotriol, tacalcitol, and calcitriol) help regulate the immune system in the skin and slow the overgrowth of skin that happens in psoriasis. They are available as ointments and liquids and are effective, safe and popular as they do not stain the skin or have a strong odour. They are not usually prescribed during pregnancy and breastfeeding and can irritate sensitive skin areas such as the face and skin folds. Treatment is applied once or twice a day, and can be continued long term. Over use of topical vitamin D analogues can cause raised blood calcium levels so the recommended weekly limit should not be exceeded. Some Vitamin D analogues are available in combination with a strong steroid as a gel, ointment or foam for short term use. It is important to understand if the Vitamin D preparation also contains a steroid as long-term use of combination products can cause skin thinning and is not recommended.
Vitamin A analogue (Tazarotene) is available as a gel that is applied once daily to patches of psoriasis. It is not suitable for use on the face or skin folds or over large areas as it often causes irritation. It must not be used during pregnancy or breast feeding.
Topical calcineurin inhibitors are anti-inflammatory preparations that were originally developed to treat atopic eczema. They may also be effective in psoriasis on the thinner skin areas of the face and skin folds (flexures). There are two preparations (Pimecrolimus cream and Tacrolimus ointment) and these are only available on prescription. They sometimes cause a burning/ prickling sensation after application. Unlike topical steroids they do not carry any risk of causing skin thinning with long term use.
What are the main topical treatments used for scalp psoriasis?
People with chronic plaque psoriasis often have lesions on the scalp ranging from mild scaling to extensive plaques with thick adherent scaling. This site can be difficult to treat and usually needs a combination of different topical agents:
Medicated shampoo containing coal tar derivatives and ingredients to remove skin scales can be helpful to manage scalp scaling in mild psoriasis.
Descaling ointments containing salicylic acid and coconut oil can be applied for several hours or overnight to treat thick scaly areas before washing out with a medicated shampoo as above. It is important to remove thick scales to allow other scalp therapies (below) to work effectively.
Topical steroids are frequently used to manage scalp psoriasis. Strong (potent) and super strong (extra potent) steroids can be used short term or intermittently and are available as lotions, gels, foam and a prescription shampoo. These are more suitable than ointments and creams for hairy areas as they are less sticky.
Vitamin D lotions and gel can also be used on the scalp and some are available as a combination with steroids.
Where can I get more information about topical treatments for psoriasis?
NICE guidance on the assessment and management of psoriasis [CG153]:
Links to patient support groups:
The Psoriasis Association
Dick Coles House, 2 Queensbridge, Northampton NN4 7BF
Tel: 0845 676 0076
Psoriasis and Psoriatic Arthritis Alliance (PAPAA)
3 Horseshoe Business Park
Links to other internet sites:
For details of source materials used please contact the Clinical Standards Unit (firstname.lastname@example.org).
This leaflet aims to provide accurate information about the subject and is a consensus of the views held by representatives of the British Association of Dermatologists: individual patient circumstances may differ, which might alter both the advice and course of therapy given to you by your doctor.
This leaflet has been assessed for readability by the British Association of Dermatologists’ Patient Information Lay Review Panel
BRITISH ASSOCIATION OF DERMATOLOGISTS
PATIENT INFORMATION LEAFLET
PRODUCED AUGUST 2004
UPDATED SEPTEMBER 2010, NOVEMBER 2013, AUGUST 2017
REVIEW DATE AUGUST 2020