**1. Introduction**

308 Psoriasis

Vena, G.A., Cassano, N., Colombo, D., et al. Cyclosporine in chronic idiopathic urticaria: a

2006;55:705–9.

double-blind, randomized, placebo-controlled trial. *J Am Acad Dermatol*

Psoriasis is a chronic and recurring inflammatory condition of the skin that affects approximately 2% of the western population (Nestle et al., 2009). The most common form is plaque type psoriasis, the treatment of which is the focus of this chapter. Patients with psoriasis often present with scaly, painful and disfiguring skin lesions (Nestle et al., 2009). Although, it is seldom life-threatening, psoriasis is associated with a high degree of morbidity - patients are embarrassed about the appearance of their skin. There are significant psychosocial issues affecting these patients, often they experience social isolation, stigmatization, alcoholism and depression. In addition, patients with psoriasis, like those with other major medical disorders, have reduced levels of employment and income as well as a decreased quality of life (Horn et al., 2007). The combined costs of long-term therapy and social costs of the disease have a major impact on healthcare systems and on society in general. There are several co-morbidities that have been linked to psoriasis and it has been hypothesized that psoriasis as a disease has important systemic manifestations (Nestle et al., 2009). The shared conditions include the metabolic syndrome, depression, and cancer. Psoriasis can also occur in association with inflammatory bowel disease (Wolf et al., 2008), diabetes mellitus (Wolf et al., 2008) and HIV infection (Maurer, 2005). Although cases have been reported, it is unclear whether cancer particularly lymphoma and skin cancer, is related to psoriasis or the long term consequences of its treatment (Gelfand et al., 2006a). The relationship between psoriasis and the risk of cardiovascular disease is of emerging significance (Gelfand et al., 2006b). While patients with mild psoriasis appears to be in no excess risk, the moderate and severe form of the disease is associated with an increase in frequency of myocardial infarction and an increase in mortality, in large part because of cardiovascular events (Gelfand et al., 2006b). If confirmed, these findings would have major implications for future preventive and therapeutic strategies. Further, it is estimated that a significant population of juvenile guttate psoriasis cases are preceded by streptococcal infections (Campalani & Barker, 2005).

For treatment purposes, psoriasis can be categorized into localized and generalized forms, based upon body surface area (BSA) involvement. For localized, mild to moderate disease, usually defined as lesions covering <10% of body surface area, topical therapy is often

<sup>\*</sup> Corresponding Author

Topical Therapies for Psoriasis 311

Although there is no cure for psoriasis, several available therapies can help control skin lesions and associated symptoms. Some treatments can also induce remission for months or longer. Despite availability of numerous topical and systemic treatment options, there is a lack of patient satisfaction with the available treatments and high rates of non-compliance. In order to optimize topical treatment of psoriasis, guidelines have been developed for more effective management of psoriasis. Some of the available guidances for topical treatment are

The American Academy of Dermatology (AAD) has published a six part series of guidelines in 2009, on the management of psoriasis and psoriatic arthritis. The third section of this series discusses the use of topical medications for the treatment of psoriasis (Menter et al., 2009). This guidance discusses the efficacy and safety of as well as offer recommendations for the use of topical corticosteroids such as vitamin D analogues, tazarotene, tacrolimus, pimecrolimus, emollients, salicylic acid, anthralin, coal tar, as well as combination therapy. The authors concluded that patients with localized psoriasis can be treated with topical agents, which generally provide a high efficacy-to-safety ratio. Topical agents may also be used adjunctively in patients with more extensive psoriasis who are undergoing therapy with either ultraviolet light, systemic or biologic medications. However, the use of topical agents as monotherapy in the generalized form of the disease or in the setting of limited, but

The Cochrane Skin Group in UK published a review of topical therapies for chronic plaque psoriasis following examination of 131 studies (Mason et al., 2009). They concluded that vitamin D analogues showed similar efficacy as potent or very potent corticosteroids when used on the body, whereas topical corticosteroids proved the most effective treatment for scalp psoriasis. Combination of topical corticosteroids and vitamin D analogues were more effective than either agent as single formulation. Although the overall safety of topical therapies was high, topical corticosteroids were associated with lower incidence of local adverse events than vitamin D analogues. Warren et. al. (Warren et al., 2010) has published a review summarizing the guidances on the use of topical, systemic and biological therapies for the treatment of psoriasis; co-morbidities associated with psoriasis; and complementary therapies for psoriasis. The UK National Health Service provides an annual evidence update on psoriasis and has included new guidelines and systematic reviews on psoriasis published or indexed from November 2008 to October 2009 in the *2009 Annual Evidence Update on* 

In Germany, Nast et. al. have developed an evidence based guidelines for topical treatment (Nast et al., 2007). The guidelines focus on induction therapy in cases of mild, moderate, and severe plaque-type psoriasis in adults and contain a series of therapeutic recommendations. A similar guideline is also available for systemic treatment of psoriasis (Pathirana et al.,

A guide has also been developed to optimize and harmonize the amount of topical medications to be applied on children (Long et al., 1998). Study conducted in children aged between 6 months to 9 years, showed that the amount of an ointment applied on children

was similar to that predicted in accordance with these guidelines (Long et al., 1998).

**2. Guidances for effective management of psoriasis** 

discussed in this section:

recalcitrant, disease was not recommended.

*Psoriasis* from NHS Evidence – Skin Disorders.

2009).

sufficient (Nestle et al., 2009). For generalized disease, systemic therapy approaches such as oral therapy, immunotherapy and UVB phototherapy are effective treatment options. In any case, the treatment plan should include obtaining rapid control of the disease and maintaining that control. In this chapter, the authors provide an overview of current guidances for topical management of psoriasis, novel mono- and combination topical therapies as well as combination regimens of topical and phototherapy. Several of the wellestablished traditional topical medications such as coal tar, salicylic acid and anthralins are only briefly reviewed here. Interested readers are referred to the following references (Su & Fang, 2008; Witman 2001) for information. An overview of the topical antipsoriatic medications is summarized in Table 1. Most of the trade names used throughout this chapter represent those marketed in United States (US).


Table 1. A summary of topical medications for psoriasis.

sufficient (Nestle et al., 2009). For generalized disease, systemic therapy approaches such as oral therapy, immunotherapy and UVB phototherapy are effective treatment options. In any case, the treatment plan should include obtaining rapid control of the disease and maintaining that control. In this chapter, the authors provide an overview of current guidances for topical management of psoriasis, novel mono- and combination topical therapies as well as combination regimens of topical and phototherapy. Several of the wellestablished traditional topical medications such as coal tar, salicylic acid and anthralins are only briefly reviewed here. Interested readers are referred to the following references (Su & Fang, 2008; Witman 2001) for information. An overview of the topical antipsoriatic medications is summarized in Table 1. Most of the trade names used throughout this

**Monotherapy** 

Betamethasone Cream, gel, lotion, foam Plaque and scalp psoriasis Mometasone Cream, ointment, gel Plaque and scalp psoriasis

Calcipotriol Ointment, cream, solution Plaque, scalp and nail

Plaque and scalp psoriasis

Plaque and scalp psoriasis

intertriginous psoriasis

psoriasis

psoriasis

psoriasis

chapter represent those marketed in United States (US).

Clobetasol propionate Ointment, spray, foam, lotion,

shampoo

**Coal tar** Ointment, gel, solution, shampoo, soap

Table 1. A summary of topical medications for psoriasis.

**Calcineurin inhibitors** *(investigational use)*

**Corticosteroids** 

**Vitamin D3 analogues** 

**Retinoids** 

**PDE4 inhibitors** 

Calcipotriol + betamethasone dipropionate

Betamethasone

acid

dipropionate + salicylic

Drug Formulation Disease Type

Halobetasol propionate Ointment Plaque psoriasis

Calcitriol Ointment Plaque psoriasis Tacalcitol Ointment Plaque psoriasis

Tazarotene Gel, cream Plaque psoriasis

**Anthralin** Ointment, cream Plaque psoriasis

Tacrolimus Ointment Face, genitelia and

AN-2728 Ointment Plaque psoriasis

Pimecrolimus Cream Intertriginous psoriasis

**Combination Product** 

Ointment Plaque, scalp and nail

Ointment, cream, lotion Plaque, scalp and nail
