13.5.2.1 Trunk and Limbs

Offer separate preparations of a potent corticosteroid and a vitamin d/vitamin D analogue used concurrently as first line.  See below for vitamin d/analogue choices and refer to section 13.4 for topical corticosteroid choices.

Vitamin D and analogues (1st line agent)

ChoiceDrugDosage
1st choice Calcipotriol 50 micrograms/g; (Dovonex®)Dose:
Apply 1-2 times daily; max 100g per week
Or
Calcitriol 3 micrograms /g; ointment (Silkis®)Dose:
Apply twice daily; max 30g daily
Or
Tacalcitol (as monohydrate) 4 micrograms/g (Curatoderm®) lotion, ointmentDose:
Apply once daily preferably at bedtime; max of 10g ointment or 10mls lotion daily

2nd choice

Combination products for where adherence is an issue

Dovobet® ointment (calcipotriol 50microgram/g, betamethasone 500microgram/g)Dose: Apply once daily for 4 weeks to a maximum 30% of body surface. If necessary treatment may be continued beyond 4 weeks or repeated on the advice of a specialist
Or
Enstilar® foam (calcipotriol 50micrograms/g, betamethasone 500microgram/g)Dose:
Apply once daily to the affected area for up to 4 weeks – consult product literature for further information; maximum 15g per day

Coal tar products (2nd line agents)

ChoiceDrugDosage
Formulary choice

Coal tar
Exorex® lotion (100mls/ 250mls) (coal tar 5% in an emollient basis)

Dose:
Apply 2-3 times a day

Prescribing Notes

  • Dual therapy of a corticosteroid and a vitamin d/vitamin d analogue is first line and should be applied separately, one in the morning and the other in the evening for up to 4 weeks as initial treatment. See NICE CG153 for further details on treatment recommendations.
  • A combination product (Dovobet®) can be used where adherence is an issue. Enstilar® is an alternative where Dovobet® ointment is not tolerated.
  • Potent to very potent topical corticosteroids are not recommended for regular use over prolonged periods because of concern over long term adverse effects.
  • NICE recommend a break of 4 weeks between courses of treatment with potent or very potent corticosteroids, such as betamethasone dipropionate which is contained in Dovobet®
  • Coal tar preparations are effective but may stain skin, hair and clothes.
  • If tar pomade (an unlicensed product) is being prescribed, it should be prescribed in “conventional proportions” which are significantly less expensive than bespoke mixtures ordered from “specials” manufacturers. The conventional proportions are:
    • coal tar solution 6%, salicylic acid 2%, emulsifying ointment to 100g; pack size is 200g
    • coal tar solution 10%, salicylic acid 6%, emulsifying ointment to 100g; pack size is 200g
  • For the long term topical treatment of plaque psoriasis a vitamin D analogue (calcipotriol) is recommended.
  • Guttate psoriasis requires emollients and perhaps a mild tar preparation such as Exorex® lotion; phototherapy may help.

Cautions

  • When different preparations containing calcipotriol are used together, the maximum total calcipotriol is 5mg in any one week (15g per day).