Joint AAD–NPF Guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures

Psoriasis is a chronic, inflammatory, multisystem disease that affects up to 3.2% of the United States population. This guideline addresses important clinical questions that arise in psoriasis management and care and provides recommendations based on the available evidence. The treatment of psoriasis with topical agents and with alternative medicine will be reviewed, emphasizing treatment recommendations and the role of dermatologists in monitoring and educating patients regarding benefits as well as risks that may be associated. This guideline will also address the severity assessment methods of psoriasis in adults. Psoriasis is a chronic, inflammatory, multisystem disease that affects up to 3.2% of the United States population. This guideline addresses important clinical questions that arise in psoriasis management and care and provides recommendations based on the available evidence. The treatment of psoriasis with topical agents and with alternative medicine will be reviewed, emphasizing treatment recommendations and the role of dermatologists in monitoring and educating patients regarding benefits as well as risks that may be associated. This guideline will also address the severity assessment methods of psoriasis in adults. DisclaimerAdherence to these guidelines will not ensure successful treatment in every situation. Furthermore, these guidelines should not be interpreted as setting a standard of care, nor should they be deemed either inclusive of all proper methods of care, or exclusive of other methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient in light of circumstances presented by the individual patient and the known variability and biological behavior of the disease. Furthermore, the treatment dosages used in clinical trials may not be effective in certain cases, and some patients may require shorter intervals between doses and/or higher treatment doses of a particular treatment methodology. This guideline reflects the best available data at the time the guideline was prepared. The results of future studies may require revisions to the recommendations in this guideline to reflect new data.Conflict of interest statementThe American Academy of Dermatology (AAD) strives to produce clinical guidelines that reflect the best available evidence supplemented with the judgment of expert clinicians. Significant efforts are taken to minimize the potential for conflicts of interest to influence guideline content. The management of conflict of interest for this guideline complies with the Council of Medical Specialty Societies Code of Interactions with Companies. Funding of guideline production by medical or pharmaceutical entities is prohibited, full disclosure is obtained and evaluated for all guideline contributors throughout the guideline development process, and recusal is used to manage identified relationships. The AAD conflict of interest policy summary may be viewed at www.aad.org.The information below represents the authors who disclosed a relationship with industry during guideline development. Authors (listed alphabetically) with relevant conflicts with respect to this guideline are noted with an asterisk (∗). In accordance with the AAD policy, fewer than 51% of workgroup members had any relevant conflicts of interest.Participation in one or more of the below-listed activities constitutes a relevant conflict:•service as a member of a speaker bureau, consultant, advisory board, for pharmaceutical companies on the psoriasis disease state or psoriasis drugs in development or United States (US) Food and Drug Administration (FDA) approved;•sponsored research funding or investigator-initiated studies with partial/full funding from pharmaceutical companies on the psoriasis disease state or psoriasis drugs in development or FDA approved.Draft guideline recommendations were developed through a collaborative approach between conflicted and nonconflicted section leaders. Initial recommendations were presented to the full workgroup for finalization.ScopeThis guideline will cover the use of topical agents and alternative medicine (AM) in the treatment of psoriasis in adults as well as the assessment of disease severity; psoriasis in the pediatric population will be covered in a separate guideline section, “Joint American Academy of Dermatology-National Psoriasis Foundation (NPF) guidelines of care for the management and treatment of psoriasis in pediatric patients.”1Menter A. Cordoro K.M. Davis D.M.R. et al.Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients [published correction appears in J Am Acad Dermatol. 2020;82(3):574].J Am Acad Dermatol. 2020; 82: 161-201Abstract Full Text Full Text PDF PubMed Scopus (0) Google ScholarMethodFor a full description of the methodology used herein, please refer to the Appendix section.Definition of reviewSee the Appendix for full definition statement.IntroductionPsoriasis is a common inflammatory disease, affecting approximately 3.2% of the population.2Rachakonda T.D. Schupp C.W. Armstrong A.W. Psoriasis prevalence among adults in the United States.J Am Acad Dermatol. 2014; 70: 512-516Abstract Full Text Full Text PDF PubMed Scopus (415) Google Scholar While skin involvement is the most prominent manifestation of this disease, recognition of psoriasis as a chronic, multisystem inflammatory disorder is imperative to optimize management and reduce comorbidities.Topical medications are the most common agents used to treat patients with mild to moderate psoriasis. They are frequently used as adjunctive therapies for patients on phototherapy, systemic, or biologic therapy. Alternative medicine (AM) is not typically part of conventional medical care. It may have origins outside of usual Western practice and may be desired by and benefit a subset of patients.3National Center for Complementary and Integrative HealthComplementary, Alternative, or Integrative Health: What's In a Name? NCCIH Clearinghouse.https://nccih.nih.gov/health/integrative-healthDate: 2019Date accessed: October 1, 2019Google Scholar,4van de Kerkhof P.C. Cambazard F. Hutchinson P.E. et al.The effect of addition of calcipotriol ointment (50 micrograms/g) to acitretin therapy in psoriasis.Br J Dermatol. 1998; 138: 84-89Crossref PubMed Scopus (0) Google ScholarThis section will review the assessment of psoriasis severity and the management and treatment of psoriasis with topical therapy and AM modalities in adult psoriasis patients (Table I).Table IClinical questions1.What are the efficacy, effectiveness, and adverse events of the following therapies used as monotherapy and/or combination therapy to treat psoriasis in adults?a.Topical corticosteroidsb.Calcineurin inhibitors (Topical tacrolimus and pimecrolimus)c.Vitamin D analoguesd.Tazarotenee.Moisturizersf.Salicylic acidg.Anthralinh.Coal tari.Biologic agent combinationj.Nonbiologic combinationi.Methotrexateii.Cyclosporineiii.Acitretin2.What are the efficacy, effectiveness, and adverse events of the following alternative medicines used for adult psoriasis?a.Traditional Chinese medicineb.Herbal therapiesi.Aloe veraii.St John's wortc.Diet/dietary supplementsi.Fish oilii.Vitamin Diii.Curcumin (Turmeric)iv.Zincv.Gluten-free dietd.Mind/bodyi.Hypnosisii.Stress reduction/meditation3.What is the accuracy, clinical utility, and treatment parameters for using the following severity measures to measure psoriasis severity and response to treatment?a.Body surface area (BSA)b.Psoriasis Area and Severity Index (PASI)c.Physician Global Assessment (PGA)d.PGA × BSAe.Psoriasis Symptom Inventory (PSI)f.Dermatology of Life Quality Index (DLQI)g.Pruritus assessment Open table in a new tab I. Topical agentsTopical corticosteroidsEfficacyTopical corticosteroids, which provide high efficacy and good safety, play a key role in the treatment of psoriasis, especially for localized disease. Topical corticosteroids have anti-inflammatory, antiproliferative, immunosuppressive, and vasoconstrictive effects. These effects are exerted via intracellular corticosteroid receptors, which regulate gene transcription, including several that code for proinflammatory mediators. Topical corticosteroids are classified into 7 categories based on their skin vasoconstrictive activity, ranging in strength from ultra-high (class 1) to low (class 6 and 7; Table II).5Cornell R.C. Stoughton R.B. Correlation of the vasoconstriction assay and clinical activity in psoriasis.Arch Dermatol. 1985; 121: 63-67Crossref PubMed Scopus (157) Google Scholar, 6Bolognia J. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier, Philadelphia2018Google Scholar, 7Gabros S. Zito P.M. Topical corticosteroids.StatPearls. Treasure Island (FL), 2019Google Scholar, 8Jacob S.E. Steele T. Corticosteroid classes: a quick reference guide including patch test substances and cross-reactivity.J Am Acad Dermatol. 2006; 54: 723-727Abstract Full Text Full Text PDF PubMed Scopus (61) Google ScholarTable IIClassification of topical corticosteroid6Bolognia J. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier, Philadelphia2018Google Scholar, 7Gabros S. Zito P.M. Topical corticosteroids.StatPearls. Treasure Island (FL), 2019Google Scholar, 8Jacob S.E. Steele T. Corticosteroid classes: a quick reference guide including patch test substances and cross-reactivity.J Am Acad Dermatol. 2006; 54: 723-727Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar∗Reprinted from Dermatology: 2-Volume Set, 4th Edition, Jean Bolognia, Julie Schafer, and Lorenzo Cerroni, Glucocorticosteroids, Page No. 2190, Copyright 2018, with permission from Elsevier.WHO potency groupClassificationTopical corticosteroidSuper-potentUltrahighClass 11.Augmented betamethasone dipropionate 0.05%aOintment.,bGel.2.Clobetasol propionate 0.05%aOintment.,bGel.,cCream.,dLotion.,eFoam.,fSolution.,gScalp solution application, in some classifications class 2.,hSpray.,iShampoo 0.05%.3.Desoximetasone 0.25%hSpray.4.Augmented diflorasone diacetate 0.05%aOintment.5.Fluocinonide 0.1%cCream.6.Flurandrenolide 4 μg/cm2jTape.7.Halobetasol propionate 0.05%aOintment.,cCream.HighClass 21.Amcinonide 0.1%aOintment.2.Betamethasone dipropionate 0.05%aOintment.3.Augmented betamethasone dipropionate 0.05%cCream.,dLotion.4.Desoximetasone 0.25%aOintment.,cCream.5.Desoximetasone 0.05%bGel.6.Augmented diflorasone diacetate 0.05%cCream.7.Diflorasone diacetate 0.05%aOintment.8.Fluocinonide 0.05%aOintment.,bGel.,cCream.,fSolution.9.Halcinonide 0.1%aOintment.,cCream.10.Mometasone furoate 0.1%aOintment.11.Triamcinolone acetonide 0.5%aOintment.Class 31.Amcinonide 0.1%cCream.,dLotion.2.Betamethasone dipropionate 0.05%cCream.,kLotion, depending upon classification, class 3 or 5.3.Betamethasone valerate 0.1%aOintment.4.Betamethasone valerate 0.12%lFoam, depending upon classification, class 3 or 4.5.Diflorasone diacetate 0.05%cCream.6.Fluticasone propionate 0.005%aOintment.7.Triamcinolone acetonide 0.1%aOintment.8.Triamcinolone acetonide 0.5%cCream.Moderate (medium)Class 41.Betamethasone valerate 0.12%lFoam, depending upon classification, class 3 or 4.2.Desoximetasone 0.05%cCream.3.Fluocinolone acetonide 0.025%aOintment.4.Flurandrenolide 0.05%aOintment.5.Hydrocortisone valerate 0.2%aOintment.6.Mometasone furoate 0.1%cCream.,dLotion.7.Triamcinolone acetonide 0.1%cCream.,mKenalog ointment (manufactured by APOTHECON, a Bristol-Myers Squibb Company; Princeton, NJ).8.Triamcinolone acetonide 0.2%hSpray.Class 51.Betamethasone dipropionate 0.05%kLotion, depending upon classification, class 3 or 5.2.Betamethasone valerate 0.1%cCream.,dLotion.3.Clocortolone pivalate 0.1%cCream.4.Fluocinolone acetonide 0.025%cCream.5.Fluocinolone acetonide 0.01%nOil.,oShampoo.6.Fluticasone propionate 0.05%cCream.,dLotion.7.Flurandrenolide 0.05%cCream.,dLotion.8.Hydrocortisone butyrate 0.1%aOintment.,cCream.,dLotion.,fSolution.9.Hydrocortisone probutate 0.1%cCream.10.Hydrocortisone valerate 0.2%cCream.11.Prednicarbate 0.1%aOintment.,cCream.12.Triamcinolone acetonide 0.025%aOintment.13.Triamcinolone acetonide 0.01%dLotion.LowClass 61.Alclometasone dipropionate 0.05%aOintment.,cCream.2.Betamethasone valerate 0.05%dLotion.3.Desonide 0.05%aOintment.,bGel.,cCream.,dLotion.,eFoam.4.Fluocinolone acetonide 0.01%cCream.,fSolution.5.Triamcinolone acetonide 0.025%cCream.,dLotion.Class 71.Dexamethasone sodium phosphate 0.1%cCream.2.Hydrocortisone 0.5%-2.5%aOintment.,bGel.,cCream.,dLotion.,fSolution.3.Methylprednisolone acetate 0.25%cCream.WHO, World Health Organization.∗ Reprinted from Dermatology: 2-Volume Set, 4th Edition, Jean Bolognia, Julie Schafer, and Lorenzo Cerroni, Glucocorticosteroids, Page No. 2190, Copyright 2018, with permission from Elsevier.a Ointment.b Gel.c Cream.d Lotion.e Foam.f Solution.g Scalp solution application, in some classifications class 2.h Spray.i Shampoo 0.05%.j Tape.k Lotion, depending upon classification, class 3 or 5.l Foam, depending upon classification, class 3 or 4.m Kenalog ointment (manufactured by APOTHECON, a Bristol-Myers Squibb Company; Princeton, NJ).n Oil.o Shampoo. Open table in a new tab Choosing a corticosteroid with appropriate potency plus the appropriate vehicle should be based on the disease severity, disease location, patient preference, and the age of the patient. Lower potency corticosteroids should be used on the face, intertriginous areas, and areas that are susceptible to steroid atrophy (eg, forearms) and other adverse effects. In adults, corticosteroids in classes 2 through 5 (moderate to high potency; Table II) are generally recommended as initial therapy. Areas with thick, chronic plaques often require treatment with class 1 (ultrahigh-potency) corticosteroids. In numerous randomized controlled trials (RCTs), different potency topical corticosteroids were effective and safe at 2 to 4 weeks in the treatment of mild to severe plaque psoriasis.9Bernhard J. Whitmore C. Guzzo C. et al.Evaluation of halobetasol propionate ointment in the treatment of plaque psoriasis: report on two double-blind, vehicle-controlled studies.J Am Acad Dermatol. 1991; 25: 1170-1174Abstract Full Text PDF PubMed Scopus (30) Google Scholar, 10Gottlieb A.B. Ford R.O. Spellman M.C. The efficacy and tolerability of clobetasol propionate foam 0.05% in the treatment of mild to moderate plaque-type psoriasis of nonscalp regions.J Cutan Med Surg. 2003; 7: 185-192Crossref PubMed Google Scholar, 11Lebwohl M. Sherer D. Washenik K. et al.A randomized, double-blind, placebo-controlled study of clobetasol propionate 0.05% foam in the treatment of nonscalp psoriasis.Int J Dermatol. 2002; 41: 269-274Crossref PubMed Scopus (48) Google Scholar Evidence on the efficacy of topical corticosteroids from RCTs varies due to the differences in study designs, patient populations, and end points, making it difficult to do an accurate statistical comparison of the majority of published studies.For ultrahigh-potency (class 1) corticosteroids, the efficacy rates in several RCTs vary from 58% to 92%.9Bernhard J. Whitmore C. Guzzo C. et al.Evaluation of halobetasol propionate ointment in the treatment of plaque psoriasis: report on two double-blind, vehicle-controlled studies.J Am Acad Dermatol. 1991; 25: 1170-1174Abstract Full Text PDF PubMed Scopus (30) Google Scholar,10Gottlieb A.B. Ford R.O. Spellman M.C. The efficacy and tolerability of clobetasol propionate foam 0.05% in the treatment of mild to moderate plaque-type psoriasis of nonscalp regions.J Cutan Med Surg. 2003; 7: 185-192Crossref PubMed Google Scholar,12Camarasa J.M. Ortonne J.P. Dubertret L. Calcitriol shows greater persistence of treatment effect than betamethasone dipropionate in topical psoriasis therapy.J Dermatolog Treat. 2003; 14: 8-13Crossref PubMed Scopus (41) Google Scholar,13Keegan B.R. Desoximetasone 0.25% spray for the relief of scaling in adults with plaque psoriasis.J Drugs Dermatol. 2015; 14: 835-840PubMed Google Scholar In a double-blind, vehicle-controlled trial of 204 patients with moderate to severe psoriasis, after 2 weeks of treatment, the halobetasol propionate ointment (class 1) group improved the Physician's Global Assessment (PGA) scores by 92% compared with 39% in vehicle-treated patients (P < .0003).9Bernhard J. Whitmore C. Guzzo C. et al.Evaluation of halobetasol propionate ointment in the treatment of plaque psoriasis: report on two double-blind, vehicle-controlled studies.J Am Acad Dermatol. 1991; 25: 1170-1174Abstract Full Text PDF PubMed Scopus (30) Google Scholar An RCT of 279 patients with mild to moderate psoriasis found that after 2 weeks of treatment with clobetasol foam (class 1), 68% of patients achieved a Physician's Static Global Assessment (PSGA) score of 0 or 1 compared with 21% of patients treated with vehicle (P < .0001).10Gottlieb A.B. Ford R.O. Spellman M.C. The efficacy and tolerability of clobetasol propionate foam 0.05% in the treatment of mild to moderate plaque-type psoriasis of nonscalp regions.J Cutan Med Surg. 2003; 7: 185-192Crossref PubMed Google Scholar Another double-blind RCT of 81 patients used the Investigator Global Assessment scale to assess patients with mild to moderate psoriasis and demonstrated that after 2 weeks of treatment with clobetasol foam (class 1), 58% of patients achieved moderate or marked improvement, or almost or completely clear psoriasis compared with 15% in vehicle-treated patients (P < .0005).11Lebwohl M. Sherer D. Washenik K. et al.A randomized, double-blind, placebo-controlled study of clobetasol propionate 0.05% foam in the treatment of nonscalp psoriasis.Int J Dermatol. 2002; 41: 269-274Crossref PubMed Scopus (48) Google ScholarFor high-potency (class 2 and 3) corticosteroids, the efficacy rates in several RCTs vary from 68% to 74%. In a double blind-RCT of 35 patients with psoriasis treated with 0.25% desoximetasone cream (class 2) for 3 weeks, 68% of the desoximetasone group compared with 23% of the vehicle group achieved improvement in their mean overall evaluation scores (P < .001).14Savin R.C. Desoximetasone—a new topical corticosteroid: short-and long-term experiences.Cutis. 1978; 21: 403-407PubMed Google Scholar Two RCTs with fluticasone propionate 0.005%, a class 3 corticosteroid, showed 68% to 69% of patients with moderate to severe psoriasis in the treatment group achieved, good, excellent, or clear skin after 4 weeks compared with 29% to 30% in the vehicle group (P = .00001).15Olsen E.A. Efficacy and safety of fluticasone propionate 0.005% ointment in the treatment of psoriasis.Cutis. 1996; 57: 57-61PubMed Google ScholarFor moderate-potency (class 4 and 5) corticosteroids, the efficacy rates in several RCTs vary from 70% to 83%.16Pauporte M. Maibach H. Lowe N. et al.Fluocinolone acetonide topical oil for scalp psoriasis.J Dermatolog Treat. 2004; 15: 360-364Crossref PubMed Scopus (33) Google Scholar,17Stein L.F. Sherr A. Solodkina G. Gottlieb A.B. Chaudhari U. Betamethasone valerate foam for treatment of nonscalp psoriasis.J Cutan Med Surg. 2001; 5: 303-307Crossref PubMed Google Scholar An RCT of 40 patients with nonscalp psoriasis revealed that 70% of patients treated with betamethasone valerate foam 0.12% (class 4) achieved greater than 50% improvement compared with 24% of patients in the placebo group after 12 weeks of treatment (P < .001).17Stein L.F. Sherr A. Solodkina G. Gottlieb A.B. Chaudhari U. Betamethasone valerate foam for treatment of nonscalp psoriasis.J Cutan Med Surg. 2001; 5: 303-307Crossref PubMed Google Scholar In an RCT of patients with moderate to severe scalp psoriasis, the group treated with fluocinolone acetonide 0.01% oil (class 5 corticosteroid) had a higher proportion of patients achieving good or better improvement from baseline compared with the vehicle-treated group after 3 weeks of treatment (83% vs 36%; P < .001).16Pauporte M. Maibach H. Lowe N. et al.Fluocinolone acetonide topical oil for scalp psoriasis.J Dermatolog Treat. 2004; 15: 360-364Crossref PubMed Scopus (33) Google Scholar Additionally, an RCT showed that fluticasone propionate 0.05% cream (class 5) was superior to hydrocortisone butyrate 0.1% cream (class 7) in achieving clearance, excellent, or good treatment response after 3 weeks of treatment (79% vs 68%; P < .05).18James M. A randomized, double-blind, multicenter trial comparing fluticasone propionate cream, 0.05%, and hydrocortisone-17-butyrate cream, 0.1%, applied twice daily for 4 weeks in the treatment of psoriasis.Cutis. 2001; 67: 2-9PubMed Google ScholarOwing to the inconsistent criteria in RCT design, comparisons between different corticosteroids and classes are complex. Nevertheless, a systematic review of topical corticosteroids for the treatment of psoriasis revealed that potent and super-potent topical corticosteroids were more efficacious than mild or moderately potent corticosteroids.19Mason J. Mason A.R. Cork M.J. Topical preparations for the treatment of psoriasis: a systematic review.Br J Dermatol. 2002; 146: 351-364Crossref PubMed Scopus (141) Google ScholarTreatment of psoriasis in intertriginous areas, such as the groin, or hair-bearing skin, such as the scalp, can be challenging due to the difficulty of applying a topical product to these areas based on the vehicle selection. Therefore, appropriate selection of the vehicle depending on hair density and individual hairstyles and preferences is essential for the efficacy of the treatment. Several RCTs and systematic reviews of scalp psoriasis treatment demonstrate the safety and efficacy of various potency topical corticosteroids used for 3 to 12 weeks.16Pauporte M. Maibach H. Lowe N. et al.Fluocinolone acetonide topical oil for scalp psoriasis.J Dermatolog Treat. 2004; 15: 360-364Crossref PubMed Scopus (33) Google Scholar,17Stein L.F. Sherr A. Solodkina G. Gottlieb A.B. Chaudhari U. Betamethasone valerate foam for treatment of nonscalp psoriasis.J Cutan Med Surg. 2001; 5: 303-307Crossref PubMed Google Scholar,20Mason A.R. Mason J.M. Cork M.J. Hancock H. Dooley G. Topical treatments for chronic plaque psoriasis of the scalp: a systematic review.Br J Dermatol. 2013; 169: 519-527Crossref PubMed Scopus (22) Google Scholar The duration of the therapy depends on factors such as the strength of topical corticosteroids, the severity of the disease, anatomic location, and age of the patient. Similarly, a steroid-sparing agent can be considered to avoid adverse effects.Additionally, intralesional corticosteroids can be used for localized nonresponding or very thick lesions on glabrous skin, scalp, nails, palms, and soles. Several studies and reports have shown that intralesional corticosteroids can be effective for the treatment of psoriasis.21Richards R.N. Update on intralesional steroid: focus on dermatoses.J Cutan Med Surg. 2010; 14: 19-23Crossref PubMed Scopus (20) Google Scholar, 22Chan C.S. Van Voorhees A.S. Lebwohl M.G. et al.Treatment of severe scalp psoriasis: from the Medical Board of the National Psoriasis Foundation.J Am Acad Dermatol. 2009; 60: 962-971Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 23Handa S. Newer trends in the management of psoriasis at difficult to treat locations: scalp, palmoplantar disease and nails.Indian J Dermatol Venereol Leprol. 2010; 76: 634-644Crossref PubMed Scopus (16) Google Scholar Triamcinolone acetonide in a dose up to 20 mg/mL can be used every 3 to 4 weeks.24Kenalog®-10 Injection (triamcinolone acetonide injectable suspension, USP) [package insert]. Bristol-Myers Squibb Company, Princeton, NJ2018https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/012041s045lbl.pdfDate accessed: April 23, 2020Google Scholar The injection volume varies pending lesional size and the area affected.Risks/harms and benefitsThe most common local skin adverse effects of topical corticosteroid use include skin atrophy, striae, folliculitis, telangiectasia, and purpura.25Abraham A. Roga G. Topical steroid-damaged skin.Indian J Dermatol. 2014; 59: 456-459Crossref PubMed Scopus (31) Google Scholar Face and intertriginous areas, as well as chronically treated areas, especially forearms, are at greatest risk to develop these adverse effects. Topical corticosteroids may exacerbate acne, rosacea, perioral dermatitis, and tinea infections and may occasionally cause contact dermatitis. Rebound (ie, when the disease recurs and is more severe than before treatment) can occur from abrupt withdrawal of topical corticosteroids, although the frequency and severity of this phenomenon are unknown. The daily use of ultrahigh- and high-potency (class 1-3) corticosteroids for up to 4 weeks is generally safe with minimal risk of skin atrophy.26Castela E. Archier E. Devaux S. et al.Topical corticosteroids in plaque psoriasis: a systematic review of risk of adrenal axis suppression and skin atrophy.J Eur Acad Dermatol Venereol. 2012; 26: 47-51Crossref PubMed Scopus (0) Google ScholarRisk of hypothalamic pituitary adrenal axis suppression from the use of topical corticosteroids for extensive plaque or scalp psoriasis has been reported to be low.26Castela E. Archier E. Devaux S. et al.Topical corticosteroids in plaque psoriasis: a systematic review of risk of adrenal axis suppression and skin atrophy.J Eur Acad Dermatol Venereol. 2012; 26: 47-51Crossref PubMed Scopus (0) Google Scholar In a systematic review of 13 randomized studies, studies performed for up to 4 weeks found the percentage of patients with a reduction in the morning cortisol level was 0% with halobetasol or fluocinonide, 0% to 48% with clobetasol propionate, and 0% to 18% with betamethasone dipropionate. Nevertheless, results of adrenocorticotropic hormone stimulation tests, the gold standard for assessing hypothalamic-pituitary-adrenal axis suppression, were always within normal reference ranges, even when assessed after 6 to 12 months of topical corticosteroid use.26Castela E. Archier E. Devaux S. et al.Topical corticosteroids in plaque psoriasis: a systematic review of risk of adrenal axis suppression and skin atrophy.J Eur Acad Dermatol Venereol. 2012; 26: 47-51Crossref PubMed Scopus (0) Google Scholar Rare systemic adverse effects include Cushing syndrome and osteonecrosis of the femoral head.27Takahashi H. Tsuji H. Honma M. Ishida-Yamamoto A. Iizuka H. Femoral head osteonecrosis after long-term topical corticosteroid treatment in a psoriasis patient.J Dermatol. 2012; 39: 887-888Crossref PubMed Scopus (0) Google Scholar,28el Maghraoui A. Tabache F. Bezza A. Ghafir D. Ohayon V. Archane M.I. Femoral head osteonecrosis after topical corticosteroid therapy.Clin Exp Rheumatol. 2001; 19: 233PubMed Google Scholar Topical products that contain corticosteroid should not be used for more than 12 weeks for nail disease, because there are isolated reports of bone atrophy with persistent use.29Malec-Milewska M. Sekowska A. Koleda I. Horosz B. Guc M. Jastrzebski J. Sympathetic nerve blocks for the management of postherpetic neuralgia-19 years of pain clinic experience.Anaesthesiol Intensive Ther. 2014; 46: 255-261Crossref PubMed Scopus (3) Google Scholar,30Rigopoulos D. Gregoriou S. Daniel Iii, C.R. et al.Treatment of nail psoriasis with a two-compound formulation of calcipotriol plus betamethasone dipropionate ointment.Dermatology. 2009; 218: 338-341Crossref PubMed Scopus (36) Google Scholar Increased intraocular pressure, glaucoma, and cataracts have been rarely reported with the use of topical corticosteroids around the eye.31Garrott H.M. Walland M.J. Glaucoma from topical corticosteroids to the eyelids.Clin Exp Ophthalmol. 2004; 32: 224-226Crossref PubMed Scopus (38) Google Scholar,32Day A. Abramson A.K. Patel M. Warren R.B. Menter M.A. The spectrum of oculocutaneous disease: part II. Neoplastic and drug-related causes of oculocutaneous disease.J Am Acad Dermatol. 2014; 70: 821.e-821.e19Abstract Full Text Full Text PDF Scopus (3) Google Scholar In rare cases, type 2 diabetes has been reported with topical corticosteroid use.33Andersen Y.M.F. Egeberg A. Ban L. et al.Association between topical corticosteroid use and type 2 diabetes in two European population-based adult cohorts.Diabetes Care. 2019; 42: 1095-1103Crossref PubMed Scopus (11) Google ScholarDespite the safety data,26Castela E. Archier E. Devaux S. et al.Topical corticosteroids in plaque psoriasis: a systematic review of risk of adrenal axis suppression and skin atrophy.J Eur Acad Dermatol Venereol. 2012; 26: 47-51Crossref PubMed Scopus (0) Google Scholar caution is advised, because the greatest risk for systemic adverse effects occurs when ultrahigh- or high-potency corticosteroids are used over a large surface (>20% body surface area [BSA]) or under occlusion for a prolonged period (>4 weeks) . Clinicians should consider limiting the use of class 1 corticosteroids to no more than twice daily for up to 4 weeks, when possible.34Clobex® [package insert]. Galderma Laboratories, L.P., Fort Worth, TX2012https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021535Orig1s003,%20021644Orig1s003lbl.pdfDate accessed: October 17, 2019Google Scholar In the event of a flare, repeated courses of a class 1 corticosteroid can be administered. Longer durations of class 1 corticosteroid therapy for psoriasis of the palms and soles are acceptable with close attention to the development of potential adverse effects. Gradual reduction in the frequency of use after clinical improvement is recommended, but the exact details of this tapering are not well established. Topical corticosteroids can be tapered off by reducing use to every other day, then eventually 2 times a week, and finally discontinuation if psoriasis is well controlled and stable during the whole process. T