Skin care and topical treatments

People who have psoriasis are advised to apply lipid-replenishing and moisture-retaining products (emollients) to their skin every day. The aim of this continuous basic treatment is to

• prevent the skin from drying out,
• prevent skin irritation and cracks in the skin, and
• reduce itching.

It's important to protect the skin like this because damaged skin can lead to new plaques. Good skin care can prevent this from happening. Various products can be used for this purpose:

• Ointments contain a lot of lipids (fatty substances) and form a thick, long-lasting protective film on the skin. They are harder to apply to the skin and may leave stains on clothing or bedding.
• Creams are less greasy and easier to apply than ointments are. They are also absorbed faster and are less visible on the skin.
• Lotions are watery and evaporate quickly. This has a cooling effect but also dries the skin out a bit.

There are no good-quality studies comparing the different types of skin care products. It's important that the products are easy to use in everyday life. Depending on your needs and the time of year, various ointments, creams and lotions can be used. For instance,

• ointments are used more in the winter, on areas of skin that are very dry or not visible, and
• creams and lotions are used more in warmer temperatures, on facial (face) skin and on the hands.

When you take a bath or shower, it's better to apply the skin care product afterwards to prevent the absorbed moisture from evaporating. If you are also treating your skin with a topical steroid, you should wait at least 15 minutes before or after applying any skin care products in order to avoid weakening the effects of the steroid. It doesn't matter whether you apply the steroid or the skin care product first.

Natural steroids are hormones that are made in the adrenal cortex. The term "steroids" (also known as corticosteroids) is often used to describe medications belonging to a group of drugs known as glucocorticoids. The steroids used in medications are made artificially. Their effects are similar to those of natural steroids.

Steroids reduce the psoriasis-related inflammation in the skin. It is the inflammation that causes the redness and makes the skin cells multiply so quickly. Steroid medications inhibit the production of hormones and chemical messengers that promote inflammation, such as prostaglandins and cytokines.

Topical steroids are available in the form of creams, solutions, ointments or – for the treatment of skin on the scalp – foams or shampoos. There are big differences between them in terms of the strength of their effect (their potency). In Germany and other countries, they are divided up into four groups based on their potency:

• Low-potency topical steroids (class I) like hydrocortisone and prednisolone
• Moderate-potency topical steroids (class II) such as prednicarbate
• High-potency topical steroids (class III), e.g. mometasone and methylprednisolone
• Ultra-high-potency topical steroids (class IV) like clobetasol

High-potency and ultra-high-potency topical steroids are often needed for the treatment of very scaly areas of skin and psoriasis on hair-covered areas of the scalp. Weaker steroids or other drugs are used on sensitive areas of the body, such as the face or in skin folds.

For the first three weeks, these medications are generally applied to the affected areas of skin once or twice a day. After that they are gradually applied less frequently – for instance, only every two days in the fourth week, and only every three days in the fifth week. The symptoms usually improve one or two weeks after the start of the treatment.

People who have frequent flare-ups may benefit from preventive treatment known as intermittent use. This involves applying the topical steroid to the affected areas of skin during (almost) symptom-free phases too. To avoid side effects, the medication is only applied on two consecutive days every week – for instance, on Saturdays and Sundays. This is sometimes referred to as "weekend treatment."

Studies have shown that high-potency topical steroids are effective: After a number of weeks, there were no more (or hardly any) visible psoriasis plaques in about

• 9 out of 100 people who hadn't used a topical steroid and
• 41 out of 100 people who had used a topical steroid.

In other words, the topical steroid led to a clear improvement in psoriasis symptoms in 32 out of 100 people.

If treatment with a high-potency steroid isn’t effective enough, the ultra-high-potency steroid “clobetasol” can be tried out. This medication was shown to be even more effective than high-potency (class III) steroids.

A lot of people are wary of using steroids, and afraid of side effects such as the skin becoming thinner. But steroids rarely cause side effects when applied to the skin: Studies have shown that less than 1 out of 100 people who use high-potency or ultra-high-potency topical steroids stop the treatment due to side effects.

Some people are worried about serious side effects such as metabolic disorders or high blood pressure. As a result, they don’t use their steroid cream or ointment for long enough, or they apply too little. But the risk of steroids causing serious side effects is very low if you only apply them to your skin (topically) and follow the instructions on the package insert.

Calcipotriol (also known as calcipotriene) is a vitamin D analogue. Other examples of vitamin D analogues include calcitriol and tacalcitol. They are only rarely used in the treatment of psoriasis, though.

Chemically-speaking, calcipotriol is closely related to vitamin D3 and similar to steroid medications. It is applied to the skin once or twice a day in the form of a cream, gel, ointment or solution. This treatment shouldn’t be used on more than 30% of the body’s surface area.

Research has shown that calcipotriol can relieve psoriasis symptoms too. But it is currently thought to be slightly less effective than high-potency topical steroids when applied to the scalp. It is also more likely to cause side effects such as burning or itching.

If treatment with one medication alone doesn’t help enough, a vitamin D analogue can be combined with a steroid medication. There are also medications that have both drugs in them.

Older topical treatments for psoriasis, such as dithranol and coal tar, are only rarely used nowadays. One reason for this is because they aren’t very easy to use compared with topical steroids or calcipotriol: They can stain your skin and clothing, and many people find the smell of coal tar unpleasant. Dithranol is mainly used in hospitals.

If psoriasis affects sensitive areas of skin – for instance on your face, in your groin area or your armpits – calcineurin inhibitors are sometimes used instead of steroids. This group of medications includes creams and ointments containing pimecrolimus and tacrolimus. Tacrolimus is the stronger of the two drugs.

Calcineurin inhibitors were originally developed for the treatment of eczema and haven’t been approved for the treatment of psoriasis. If they are used for the treatment of psoriasis, it is known as "off-label use" and certain conditions apply. It's also important to contact your health insurer before starting the treatment in order to find out whether they will cover the costs.

There’s a lack of good-quality research on the effectiveness of calcineurin inhibitors in the treatment of psoriasis. Because of this, it’s not possible to say whether they work as well as steroids do.