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7/31/2019 http://www.dermexchange.org/research/guidelines/_doc/Pso3Topicals.pdf
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FROM THE ACADEMY
Guidelines of care for the management of psoriasisand 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 Steven R. 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 Henry W. Lim, MD, j Abby S. Van Voorhees, MD, k
Karl R. Beutner, MD, PhD, h,l and Reva Bhushan, PhD m
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, inammatory, multi-system disease with predominantly skin and jointmanifestations 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 withtopical agents, which generally provide a high efcacy-to-safety ratio. Topical agents may also be usedadjunctively 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 efcacy 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
successful treatment in every situation. Furthermore,these guidelines should not be deemed inclusive of all proper methods of care nor exclusive of othermethods of care reasonably directed to obtainingthe same results. The ultimate judgment regardingthe propriety of any specic therapy must be madeby the physician and the patient in light of all thecircumstances presented by the individual patient.
SCOPEThis third section covers the management and
treatment of psoriasis with topical therapies.
Abbreviations used:
AAD: American Academy of Dermatology HPA: hypothalamic-pituitary-adrenal (axis)PASI: Psoriasis Area and Severity IndexPGA: physicians global assessment
From the Baylor University Medical Center, Dallas a; Department of Dermatology, Murdough Family Center for Psoriasis, Depart-ment of Dermatology, University Hospitals Case Medical Cen-ter, Cleveland b ; Department of Dermatology, University of Alabama at Birmingham c; Department of Dermatology, WakeForest University School of Medicine, Winston-Salem d ; Depart-ment of Dermatology and Center for Clinical Epidemiology andBiostatistics, University of Pennsylvania, Philadelphia e ; Divisionof Dermatology, Evanston Northwestern Healthcare and De-partment of Dermatology, Northwestern University, FeinbergSchool of Medicine, Chicago f ; Tufts Medical Center, TuftsUniversity School of Medicine, Boston g ; Department of Derma-tology, University of California e San Francisco h ; Department of
Dermatology, Mount Sinai School of Medicine, New York i
;
Department of Dermatology, Henry Ford Hospital, Detroit j;Department of Dermatology, University of Pennsylvania, Phil-adelphia k ; Anacor Pharmaceuticals, Inc, Palo Alto l; and Amer-ican Academy of Dermatology. m
Funding sources: None.The authors conflict of interest/disclosure statements appear at
the end of the article.Reprint requests: Reva Bhushan, PhD, 930 E Woodfield Rd,
Schaumburg, IL 60173. E-mail: [email protected] .Published online February 17, 2009.0190-9622/$36.00 2009 by the American Academy of Dermatology, Inc.doi:10.1016/j.jaad.2008.12.032
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mailto:[email protected]:[email protected]

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METHOD A work group of recognized psoriasis experts was
convened to determine the audience for and scopeof the guideline and to identify clinical questions tostructure the primary issues in diagnosis andmanagement discussed in American Academy of Dermatol og y (AAD) psoriasis guidelines Sections1 and 2.1,2 Work group members completed adisclosure of commercial support.
An evidence-based model was used and evidence was obtained using a search of the MEDLINE data-base spanning the years 1960 through 2008.
The available evidence was evaluated using a uni-ed system called the Strength of RecommendationTaxonomy developed by editors of the US family medicine and primary care journals (ie, American Family Physician , FamilyMedicine , Journal of Family Practice ,and BMJUSA).This strategywassupported by a decision of the Clinical Guidelines TaskForce in 2005 with some minor modifications for a consistent ap-proach to rating the strength of the evidence of scientific studies. 3 Evidence was graded using a 3-point scale based on the quality of methodology asfollows:
I. Good-quality patient-oriented evidenceII. Limited-quality patient-oriented evidence
III. Other evidence including consensus guidelines,opinion, or case studies
Clinical recommendations were developed on the
best available evidence tabled in the guideline.These are ranked as follows: A. Recommendation based on consistent and good-
quality patient-oriented evidenceB. Recommendation based on inconsistent or lim-
ited-quality patient-oriented evidenceC. Recommendation based on consensus, opinion,
or case studies
In those situations where documented evidence-based data are not available, we have utilized expertopinion to generate our clinical recommendatio ns.Prior guidelines on psoriasis were also evaluated. 4,5
This guideline has been developed in accordance with the AAD/AAD Association AdministrativeRegulations for Evidence-based Clinical PracticeGuidelines, which include the opportunity for review and comment by the entire AAD membershipand final review and approval by the AAD Board of Directors.
GENERAL PRINCIPLES Approximately 80% of patients affected with
psoriasis have mild to moderate disease. The ma-
jority of these patients can be treated with topical
agents which generally provide both high efcacy and safety. Topical agents are also used adjunc-tively for resistant lesions in patients with moreextensive psoriasis who are being concurrently treated with either ultraviolet light or systemicmedications. However, the use of topical agentsas monotherapy in the setting of extensive diseaseor in the setting of limited, but recalcitrant disease isnot routinely recommended. Treatment should betailored to meet individual patients needs. Theseneeds vary depending on body location, character-istics of the psoriasis being treated including lesionthickness, degree of erythema and amount of scaling, as well as patient preferences. It is impor-tant to match patient expectations with practicalconsiderations. Patients who wish for lifetime clear-ance with no evident lesions will inevitably bedisappointed with topical therapy because of theneed for a continuous intense topical regimen that will be very difcult to carry out and maintain.Some patients may desire to be free from pruritusand to have a diminution in their most visiblelesions. Others may prefer only intermittent treat-ment with little interest in spending considerabletime to care for their psoriasis. It is important toascertain each patients goals and then to develop astrategy to help fulll his or her expectations whilealso being practical and realistic.
The choice of vehicle can signicantly alter theuse and penetration of the medication and thereforealter the efcacy. Vehicle types are numerous andmay include ointments, creams, solutions, gels,foams, tape, sprays, shampoos, oils, and lotions.Different vehicles are indicated for different body sites. The optimal choice is generally the vehicle theindividual patient will most likely use. For example,hair-bearing areas including the scalp can be treated with solutions, foams, shampoos, sprays, oils, gels,or other vehicles, with individual patients havingdifferent preferences among these options. Somepatients may prefer a less greasy preparation, per-haps a cream for daytime use and may be willing to
use an ointment, which is more effective but lesscosmetically appealing, at night. Cultural prefer-ences may also make one vehicle preferred overothers for a given site. Occlusion of topical medica-tions can also alter the penetration, thereby varyingthe effectiveness. The observation that urandreno-lide 0.1%, which is a class 5 topical steroid when usedin the cream or lotion formulation, functions as aclass 1 topical steroid when used as a tape and has ahigher efcacy than the class 1 steroid diorason ediacetate ointment in the treatment of psoriasis 6
serves as a strong reminder of the impact of
occlusion.
J A M A CAD D ERMATOL A PRIL 2009
644 Menter et al

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Topical medications can sometimes be used con-currently to take advantage of varied mechanisms of action. For example, calcipotriene can be used incombination with topical corticosteroids. However, when using multiple topical

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