(Examples: betamethasone, hydrocortisone, etc.)

What it does / How it works

Corticosteroids are synthetic versions of hormones made in the body and are the most commonly prescribed medications for psoriasis flares. When applied to the skin, topical corticosteroids reduce inflammation, making them useful for psoriasis. Their potency can range from low to very high (see table below for classification of common topical corticosteroid therapies). The dosage form and potency are usually selected based on the severity of disease, which area is affected, and patient preference. Lower potency corticosteroids are best for sensitive areas such as the face, groin, armpits, backs of knees, and the inside of elbows. Areas with thick or widespread plaques may require higher potency corticosteroids.

Time frame

Patients may begin to see improvement 1 or 2 weeks after starting treatment with an appropriate corticosteroid. Use of these medications is often limited to a course of 2 to 4 weeks at a time to reduce side effects.

Dosage Form

Topical corticosteroids are available in a variety of formulations including creams, lotions, foams, gels, ointments, sprays, and shampoos. 

Learn more about the differences between these topical dosage forms

Dose and frequency

Topical corticosteroids are usually applied to the affected areas once or twice a day. After psoriasis symptoms resolve, the medication is gradually reduced by changing to a lower potency corticosteroid or by reducing the frequency of use. It is important to follow the doctor’s specific instructions to prevent rebound outbreaks after stopping therapy.

Potential side effects

With extensive, non-supervised, and prolonged use of high potency topical steroids, over a large surface area you may notice side effects such as :

• Fragile, thin skin
• Easy bruising
• Noticeable small blood vessels on your skin
• Bands of thin, red skin that fade to pale streaks (stretch marks)
• Infection of hair follicles
• Tiny red or purple spots
• Hair growth on the sites of application

Topical corticosteroids can worsen rosacea, perioral dermatitis,  athlete’s foot and similar infections. If high-dose corticosteroids are used over a large area for over 3-18 months^[REF], it’s possible for rare systemic side effects to appear such as Cushing’s syndrome, cataracts, glaucoma or osteoporosis. It is important to follow any instructions your doctor gives you about using a topical corticosteroid. Talk with your dermatologist or healthcare provider before bandaging over corticosteroids as occlusive dressings can increase absorption of the medication and increase the risk of side effects.  

How to manage side effects

Talk to your doctor or pharmacist if you suspect you are experiencing medication side effects.

Other topical therapies such as vitamin D analogues, topical retinoids, and calcineurin inhibitors can be used long-term to reduce the recurrence of psoriasis after the discontinuation of topical corticosteroids. These treatments are sometimes referred to as steroid-sparing agents because they can reduce the need for topical corticosteroids which can help to limit steroid-related side effects. There is some controversy over whether people can develop a resistance to topical corticosteroids over time.

Cost considerations

Some topical corticosteroid treatments are available as generics. Generic medications are just as effective and safe as the brand name medication but are less expensive. 

Corticosteroid Potency Table 

(This is not an exhaustive list)

REFERENCE: Joint AAD–NPF Guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures, Crossref DOI link: https://doi.org/10.1016/J.JAAD.2020.07.087, Published: 2021-02

(Examples: calcipotriol and calcitriol)

What it does / How it works

Vitamin D derivatives reduce the excessive production of skin cells that occurs in psoriasis and return the growth of skin cells to normal. 

Vitamin D3 derivatives are corticosteroid-sparing – they enable you to use less topical corticosteroid. When combined with topical corticosteroids, they can often work better than either medication alone.

Time frame

It can take up to 8 weeks of treatment to see symptom improvement. 

Dosage Form

Vitamin D3 derivatives or analogues are available as ointments, gels, and foams typically for the treatment of mild to moderate psoriasis. They are also available in combination products containing topical corticosteroids. 

Dose and frequency

Vitamin D analogues are usually applied once or twice daily for about 8 weeks. Long-term use (up to 52 weeks) of vitamin D analogues has also been studied and is considered safe. However, these medications should not be used on the face due to risk of side effects such as itching and redness.

Studies suggest that combining vitamin D analogues with other treatments such as topical corticosteroids, cyclosporin, or acitretin, improves efficacy while reducing side effects of each agent since a lower dose may be used. 

These are general dosing guidelines and individuals should always follow the specific instructions provided by their doctor.

Potential Side Effects

Common side effects include burning, itchiness, swelling, peeling, dryness and rash. 

In patients who spread larger doses over much of their body, vitamin D3 derivatives may cause a rise in blood calcium levels, which reverses when the medication is stopped. They may also cause light sensitivity and may cause a burning sensation if applied before UVB phototherapy. 

How to manage side effects

Talk to your doctor or pharmacist if you suspect you are experiencing medication side effects. Make sure to wash your hands after applying the medication to avoid accidentally transferring the medication to your face.

Patients who apply vitamin D analogues over large areas of the body may need to have their blood calcium levels checked. If your serum calcium levels are found to be too high, the medication may need to be temporarily stopped.

Cost considerations

Currently, only betamethasone/calcipotriol combination ointment is available in Canada as a generic (Brand Name: Dovobet). Generic medications are just as effective and safe as the brand name medication but are less expensive.

Learn more about public health coverage in your province.

What it does / How it works

Tazarotene is a vitamin A-based treatment (topical retinoid) that works by exfoliating the skin, causing dead skin cells to slough off, and promoting the production of new, healthy skin cells. This medication can help to reduce plaques, scaling, and redness. Combining tazarotene with UVB phototherapy may also reduce the amount of UV exposure needed for effective treatment.  

Time frame

Tazarotene may be used for 8 to 12 weeks to treat mild to moderate psoriasis.

Dosage Form

Tazarotene is available as a gel or a cream.  A combination product containing tazarotene and halobetasol (a topical corticosteroid), is currently available as a lotion. When combined with topical corticosteroids, tazarotene can help prevent thinning of the skin, which is a common side effect of corticosteroids. 

Dose and frequency

Tazarotene is usually applied to psoriatic lesions once daily in the evening. Patients usually start with tazarotene 0.05% cream and increase to 0.1% cream only if tolerated and medically necessary. 

Monitoring and follow up

Retinoids have a high risk of causing developmental malformations of an embryo or fetus. For this reason, women of child-bearing age should get a negative pregnancy test about 2 weeks before starting tazarotene and consider options for contraception with their family doctor. Patients who become pregnant while using a topical retinoid should follow up with their physician immediately.  

Potential Side Effects

Common side effects include dry skin around the areas of application as well as burning, itching, and redness.

How to manage side effects

Dry, irritated skin can be managed by moisturizing, changing the frequency of application to every other day, using a less potent alternative, using short-contact (30- to 60-minute) treatments, combining this product with a topical corticosteroid or avoiding contact with non-psoriatic skin. If a moisturizer is used, it should be applied at least an hour before tazarotene. 

Cost considerations

Talk to your pharmacist about drug coverage options available to you. Tazarotene may not be eligible 

Moisturizers (emollients) leave a film on the skin’s surface, forming a barrier to retain moisture in the skin’s upper layers. These products may be soothing and may help remove the scales that form in psoriatic plaques. They may also increase the effectiveness of other topical treatments. Using a moisturizer up to three times daily is add-on therapy for psoriasis—it will not control flares on its own.

Salicylic acid can reduce scaling and soften the reddish patches (plaques) of psoriasis. It is often combined with other topical agents and may come as a lotion, cream, gel, or shampoo.  Strengths greater than 20% should not be used on the body. It is not recommended for use in children or people with liver or kidney problems. This agent can reduce the effectiveness of UVB phototherapy, and it can interact with certain oral medications. Common side effects include redness, scaling, and local irritation. Salicylic acid is found in both prescription and non-prescription products. Your pharmacist can help you understand what treatment options are available and how best to use the medication.

Anthralin is a yellowish cream that is mostly used as short-contact (20- to 30-minute) therapy for mild to moderate psoriasis and hard-to-treat scalp psoriasis. Its inconvenience and poor cosmetic appearance are its major downfalls. It is not as effective as prescribed topical corticosteroids or vitamin D derivatives. Anthralin can stain the skin, clothing and other objects that are touched. Other side effects include skin irritation. It is no longer commercially available but can be compounded by pharmacists.

Coal tar preparations are not used as often as they once were to treat psoriasis. Today, they are available mostly as over-the-counter shampoos and gels for mild to moderate psoriasis. Formulations are not standardized, and the effectiveness of coal tar differs from one preparation to the next. For example, some studies have found that 1% lotion works better than 5% coal extract. Odour, staining and cosmetic issues can discourage many patients from using coal tar. Potential side effects include photosensitivity to UVA light, contact dermatitis and infection of hair follicles.

Ingredients such as coal tar and salicylic acid are found in various over-the-counter products. You should always check the label to identify the strength of the ingredient used and the dosage form (i.e. cream, ointment, etc.). Your pharmacist can help you select an appropriate over-the-counter therapy. The selection of product may depend on the severity of disease and location of lesions. Over-the-counter therapies may be used as an add on to prescription treatments. Tell your pharmacist or doctor about any over-the-counter treatments you are taking so that they can manage or prevent any interactions with your prescription drugs.

Some topical retinoids such as retinol and retinaldehyde are available without a prescription and are commonly added to cosmetics. While prescription retinoids such as tazarotene have been studied in psoriasis and have demonstrated benefits, there is limited evidence available for the non-prescription retinoid products used in cosmeceuticals (i.e. anti-aging creams). Non-prescription topical retinoids are generally lower in potency and thus will not achieve the same benefits as prescription treatments. 

REFERENCE: [https://academic.oup.com/asj/article/30/1/74/199813] 

Low potency corticosteroids such as hydrocortisone 0.5% and hydrocortisone 1% are available without a prescription. This medication is sometimes prescribed for psoriasis of the face or skin folds. Talk with your pharmacist for more information when purchasing products over the counter. These products may cause side effects and should not be used long term.  

Since there are so many over-the-counter formulations, I have opted to include a blanket statement about otc therapies

What it does / How it works

Roflumilast is a non-steroid selective inhibitor of phosphodiesterase 4 (PDE4), used for the topical treatment of plaque psoriasis, including treatment of psoriasis in the intertriginous areas, in patients 12 years of age and older.

How it is used

Apply roflumilast topically once a day to affected areas of the skin and rub in completely. Wash hands after application unless hands are the affected areas being treated.

If deemed medically necessary to use during breast-feeding, use roflumilast on the smallest area of the skin for the shortest duration possible. Do not apply roflumilast directly to the nipple and areola to avoid direct infant exposure.

Roflumilast is for topical use only and not for ophthalmic, oral, or intravaginal use.

Usual Dose

Apply Roflumilast cream to affected areas once a day.   If you forget to apply roflumilast, skip the missed dose and go back to your regular dosing schedule the following day.

Monitoring and follow up

Roflumilast is contraindicated in patients with moderate to severe liver impairment (Child-Pugh B or C), and patients who are hypersensitive to this drug or to any ingredient in the formulation, including any non-medicinal ingredients, or components of the container.

Roflumilast should not be used during labor and delivery. Roflumilast should only be used by a breast-feeding mother if deemed medically necessary, considering a potential risk to the baby. To minimize potential exposure to the breastfed infant via breast milk, use roflumilast on the smallest area of skin and for the shortest duration possible while breastfeeding. Do not to apply roflumilast directly to the nipple and areola to avoid direct infant exposure.  

Potential Side Effects

The most common adverse drug reactions reported in clinical trials among patients with plaque psoriasis 12 years of age and older are diarrhea and headache. To obtain a comprehensive list of all known potential side effects of roflumilast, talk to your doctor or pharmacist. 

Cost considerations

Talk to your pharmacist about drug coverage options available to you.