Psoriasis – topical treatments

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 a topical treatment is, how it is used and how to find out more about it. Please note that some of the treatment options in this leaflet may not be available on the NHS.

What are topical treatments?

A topical treatment is something that is applied directly to the skin. Most people with mild psoriasis are able to manage their skin problem with topical treatments. Psoriasis that covers large areas may need other treatments such as light therapy, tablets or injections. See patient information leaflet “Treatments for moderate or severe psoriasis”. Topical treatments feel, look and smell different, the table below explains some common differences between products.

Topical Treatments Key points
Lotion Thin and feels lighter
Cream Thicker than lotion
Ointment Thicker than cream
Gel Water based and so often thinner than ointments
Shampoo Important to massage into scalp and leave on as per instruction before rinsing off
Foam A liquid with bubbles within in
Scalp application Thin liquid designed to use on scalp

Need to part hair to expose plaques if using in hairy areas

Medicated plasters Large film plasters or tape, that can be cut to size and placed on skin for 24 hours before changing

 

What is psoriasis?

Psoriasis is a common skin problem affecting 1 in 50 people. It can appear at any age, in any skin type and in any sex, 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 it can cause a short-term lightening or darkening of skin colour. Psoriasis is usually a long-term condition but there are many good treatments.

Psoriasis can affect the nails and the joints (psoriatic arthritis) as well as the skin. About half of people with psoriasis have psoriasis affecting their nails on their hands and feet. For people with moderate to severe psoriasis, about one in three will develop psoriatic arthritis at some time. Psoriasis in the joints produces swelling and stiffness or just stiffness if it is in the spine and should be managed by a rheumatologist.

Can psoriasis be cured?

There is no cure for psoriasis yet. Psoriasis can be improved, and sometimes cleared, by regular use of a treatment or several treatments. Psoriasis can come 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 treatments are to remove excess scaly skin and calm the redness. This will improve the appearance and help the skin feel more comfortable. Different treatments are often used at different body sites and sometimes, a combination of treatments may be needed to get the best results. Some of these creams need prescriptions, but others are freely available to buy.

Treatments for psoriasis include the following:

  • Emollients (moisturisers) work by moisturising dry skin and reducing dry skin flakes. They soften cracked areas and help other topical treatments get through the skin and work better. They can also be used instead of soap.  It is usually advised that they are applied about 30 minutes before other psoriasis treatments (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. As these emollients also soak into fabrics, it is important that you change your clothing and bedding regularly.  Some people may wear bandages or garments under the clothes to stop the topical treatments soaking through.

We advise that you do not smoke / use naked flames / go near anything that may cause a fire if you have oil based topical treatments on your skin and clothes (see CAUTION below).

  • Topical corticosteroids work by reducing skin inflammation (seen as redness on the skin). They are available in different strengths, namely mild, moderate, potent (strong) and very potent (extra strong). Mild topical steroids can be helpful on the face or in the skin folds (e.g. under the arms). Very potent corticosteroids are usually reserved for palms and soles as the skin is much thicker in those areas. If potent or very potent corticosteroids are used on the same area of skin for many months or years, there is a small risk of skin thinning so ongoing prescriptions should be monitored by your doctor.
  • Combination products Many topical treatments have more than one treatment in them. Most of these will contain a topical steroid plus another active ingredient such as Vitamin D like chemicals or salicylic acid.
  • Vitamin D like chemicals (e.g. calcipotriol, tacalcitol, and calcitriol) help improve psoriasis. They are 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.
  • Topical calcineurin inhibitors (e.g. pimecrolimus and tacrolimus)work by reducing skin inflammation (seen as redness on the skin). They are safe anywhere, including the face and skin folds (flexures). They sometimes cause a burning/ prickling sensation after application but this often eases over a few days to weeks.
  • Salicylic acid can help reduce excessive scaling but may sometimes irritate the surrounding skin. It is generally used on thick areas of skin to reduce the thickness.
  • Vitamin A topical treatment (e.g. tazarotene)helps improve psoriasis. It is not suitable for use on the face or skin folds or over large areas as it can irritate. It must not be used during pregnancy or breast feeding.
  • Tar preparations reduce the thickness of the 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. They are safe.
  • Dithranolis useful for stubborn areas of psoriasis on ‘non-delicate’ skin such as elbows and knees.  It is usually given as ‘short contact therapy’ at home but it is increasingly difficult to get hold of. Dithranol is put on the 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 over weeks. Occasionally dithranol causes irritation of the treated area and surrounding skin and treatment needs to be stopped or a weaker preparation used.

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.

What are the main topical treatments used for scalp psoriasis?

People with psoriasis often have lesions on the scalp. This site can be difficult to treat and usually needs a combination of different topical agents.

  • Topical steroids are frequently used to manage scalp psoriasis. Potent and very potent steroids are often used 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. The skin is much thicker on the scalp so there is less concern of developing side effects from using topical steroid on the scalp.
  • Vitamin D like chemicals can also be used on the scalp, however, these have been shown to be less effective compared to topical steroids for scalp psoriasis. There are combination products containing both topical steroid and Vitamin D like chemicals that are effective.
  • Medicated shampoos containing ingredients including coal tar, coconut and salicylic acid can be helpful to manage scalp scaling (dandruff) 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 shampoo.  It is sometimes easier to rinse off the descaling ointment by applying shampoo to dry hair before getting it wet.
Using descaling ointment and medicated shampoos

1. Part the hair and apply the descaling ointment onto the psoriasis

2. Leave on for one hour or overnight

3.  Put an old towel over the pillow to avoid staining if leaving overnight

4. Wash off with shampoo (massage into scalp and leave on for 5-10 minutes before rinsing off – sometimes easier if hair is still dry at this point)

5. Use a comb to remove the dandruff that have come off

Please watch our videos for further advice:

www.skinhealthinfo.org.uk/support-resources/video-guides/

Where can I get more information about topical treatments for psoriasis?

NICE guidance on the assessment and management of psoriasis [CG153]:

http://www.nice.org.uk/guidance/cg153/informationforpublic

Links to patient support groups:

The Psoriasis Association

Dick Coles House, 2 Queensbridge, Northampton NN4 7BF

Tel: 0845 676 0076

Web:www.psoriasis-association.org.uk

 

Psoriasis and Psoriatic Arthritis Alliance (PAPAA)

3 Horseshoe Business Park
Lye Lane

Bricket Wood

St Albans

Hertfordshire

AL2 3TA

www.papaa.org

Links to other internet sites:

http://www.patient.co.uk/health/psoriasis

For details of source materials used please contact the Clinical Standards Unit (clinicalstandards@bad.org.uk).

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, DECEMBER 2021
REVIEW DATE DECEMBER 2024

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