Coupon Accepted Successfully!


Topical Agent in Psoriasis

The various topical agents being used in psoriasis are:

  1. Tars preparations- Goeckerman regimen
  2. Anthralin (Dithranol)- Ingram regimen
  3. Topical coritcosteroids: variety of strengths, vehicles, intralesional
  4. Vitmain D analogues :Calcipotriene, Calcitriol, Tacalcitol, Maxacalcitol
  5. Retinoids: Tazarotene, Bexarotene
  6. Keratolytic agents: salicylic acid, lactic acid, urea
  7. Emollients
  8. Combinations  of above agents
  1. Emollient
    1. Tar
      Pinetar, Coal tar are all useful. They can be in the lotion, shampoo, cream, paste, ointment forms. Goeckerman's regimen.
    2. Topical steroid
    3. Dithranol
      0.25% dithranol in Lassar paste can be tolerated by some patients with plaque type psoriasis at the shins, elbows and knees and with good therapeutic result. Adjunctive phototherapy as in Ingram regimen will be very helpful but only is possible in in-patient or day care centre. The commercial preparation of 1 to 4% Dithranol ointment is good for the SCAT (Short contact Anthranol therapy). It is because the staining and stinging sensation that most patient dislike this regimen.
  2. Systemic Therapy
    Systemic agents-
    1. Methotrexate
    2. Acitretin
    3. Cyclosporine
    4. Hydroxyurea
    5. Mycophenolate Mofetil
    6. 6- Thioguanine
    7. Fumaric acid esters
​​This list followed by drug description what written already in notes
  1. Etretinate
    The initial dose will be between 0.5 mg and 1 mg/kg/day. The response is very often dose related. Dose reduction is possible when it is used in combination with phototherapy or photochemotherapy. They are one of the most effective combination in clearing psoriasis. Etretinate alone seldom can control psoriasis perfectly and useful adjunctive therapy with phototherapy, PUVA, steroid cream will be very synergistic. It may also be used in generalized pustular psoriasis although methotrexate works as good or better.

    Absolute contraception must be practiced in some difficult case and
     this must be continued for two years after stopping the medication (because of high lipophilic property and long elimination half-life of 80 days).
  2. Methotrexate
    It is a magic drug for psoriasis provided adequate monitoring is provided. It is given as once weekly to once biweekly doses.
  3. Hydroxyurea
  4. Cyclosporin A
    This is a powerful medication. Improvement may be seen within few days with a dose of 3 mg/kg/day. If there is no improvement within 2 weeks, the dose may be increased by 0.5 to 1 mg/kg/day at a 2-weekly interval to a maximal dose of 5 mg/kg/day. Maintenance dose should be reduced to the smallest dose that allows adequate control. Relapse is inevitable after cessation of treatment but fortunately rebound is not a problem.
  5. Phototherapy and Photochemotherapy
    1. Narrowband UVB
    2. Excimer Laser
    3. Psoralen and UVA light (PUVA)
  1. Investigational therapies
    1. Immunotherapy
      1. Mycobacterium vaccae                                  
      2. Mycobacterium w             
      3. Psoraxine                        
    2. Peptide-T
    3. Tyrosine kinase inhibitors
    4. p38 MAPK inhibitor
    5. Protein Kinase C Inhibitors
Goeckerman Regimen
This is mainly a regimen for in-patient or day care centre patient.
Goeckerman – 1-5% coal tar
Ingram – 0.1 – 0.5% Anthralin (Dithranol)
  1. Ingram Regimen
    It is similar to that of Goeckerman regimen except that 0.25% Dithranol in (Lassar Paste) is applied instead of 1% crude coal tar.
    Lassar parle → a. Petrolatum   b. Salicylic acid  c. Zno   d. Starch
  2. PUVA (Systemic and Topical)
    0.6 mg/kg of 8-methoxypsoralen is taken orally by patient 2 hours before irradiation with UVA (320-400 nm).
    Eye protection is important. During irradiation and after taking the drug that day, patient must wear UVA opaque goggles to prevent cataract and acute photosensitivity of the eyes. Patient is required to have treatment at the day care centre two to three times a week. Patients with cutaneous malignancy potential are excluded for PUVA e.g. Arsenic ingestion, radiotherapy. PUVA is of value in generalized pustular psoriasis, erythrodermic psoriasis, chronic palmoplantar pustular psoriasis.

    Selective UVB Phototherapy (UV sources with peak effective output in the 300-320 nm range):
    Psoralen-311 nm therapy: a narrow-band UVB source emitting 311 nm (compared with conventional PUVA: peak emission at 352 nm) are shown to be effective. The 311 nm UVB phototherapy alone is also effective. This source of UVB light has avoided the non-therapeutic but erythemogenic UVB (of wavelengths of less than 300 nm). Low intensity selective UVB phototherapy (LISUP) has been designed for home use but they are probably less effective than conventional phototherapy. hronic psoriatics.)
    BRM - Biological Response modifies
    Etanercept (Anti TNFx), Infliximab (TNF); Efalizumab.

Summary of Treatment






Tar (Goeckerman)


Effective, safe; concerns about poss-

ible Carcinogenicity remain theoretical

Limited efficacy

Messy, inconvenient, smelly, long contact time required; tar extracts are less effective than crude coal tar, but more convenient and more pleasant to use

Dithranol (anthralin)


Effective, safe; prolonged remission;

short contact time (1/2 hour) often


Dithranol stains skin, clothing, towels, Dithranol stains skin, clothing, towels, baths and upholstery; irritation may limit efficacy


Effective, clean and convenient Short duration of remission necessitates


constant treatment ; risk of cutaneous   atrophy and rebound of psoriasis on


Vitamin D analogues



Effective, clean and convenient

Short duration of remission necessitates constant treatment; irritant reactions constant treatment; irritant reactions may occur; risk of hypercalcemia with overdose (safety margins are good, but established only in psoriasis vulgaris); greasy vehicle


Less irritant than tacalcitol and calcipotriol; can be used on face and flexors




Clean and convenient

Relatively new approach, so    experience remains limited; irritant, limited efficacy, teratogenic

Calcineurin inhibitors


Effective only on thin plaques

Should not be combined with phototherapy transient burning sensation is common


Systemic Treatments in psoriasis





Relatively safe, except in

fertile women

 Teratogenicity, slow onset of action, cracked lips, hair thinning (reversible), raised plasma lipids



Can be used in patients with

mild renal or hepatic impairment

Nephrotoxicity, hypertension, Munosuppression seen within 2 weeks), highly relatively high cost effective


Highly effective, very low cost

Marrow suppression

Fumaric acid esters

Relatively safe

Nausea, marrow suppression, hepatic fibrosis;  Hazardous in patients with renal or hepatic  Impairment Slow onset of action; flushing, diarrhea and (unlicensed in UK) lymphopenia

Test Your Skills Now!
Take a Quiz now
Reviewer Name