<p>Topical corticosteroids are a cornerstone of plaque psoriasis treatment. Despite the long-established use of these therapeutic options, with increased treatment choices available, an individualized evaluation of the impacted area and a discussion regarding patient goals, patient preferences, and potential benefit are still important aspects of treatment selection.</p>

When a patient has plaque psoriasis involving 5% or less of their body surface area (BSA), they are often an appropriate candidate for a trial of topical therapy. However, there are instances in which topical therapy might not be appropriate, even when BSA is low. If a patient has plaques that might be very difficult to treat based on thickness, heavy scale, or location, you might choose a systemic therapy right away. Topicals also may not work in patients with palmoplantar disease, as they can have very thick plaques and tremendous debilitation. All that said, for the most part, the general rule is that patients with lower BSA involvement deserve a trial of a topical. I usually choose a very high-potency topical therapy to start, but I am beginning to opt for topical nonsteroidals such as tapinarof or roflumilast more often. These are slower to work than topical corticosteroids; it will take 4 to 8 weeks on a nonsteroidal to see significant benefit.

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Another scenario in which topical treatments may be used is in combination with a systemic therapy or phototherapy. Topicals can be used adjunctively in patients who do well on systemics—perhaps in those whose disease clears by 85%—but who have residual disease over a small BSA that could be treated by a topical therapy. I do not use topicals in people with disease over more than 7% BSA. That would be impractical for the patient and in terms of the amount of topical required. Even though some recent studies allowed up to 20% BSA in enrolled patients, I feel that it is inappropriate to use topical agents over such large areas.

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Adherence considerations are incredibly important when selecting treatment. We know that patients prefer once-daily application to twice daily. It can also help to choose a single topical that is appropriate for the entire body. That is an advantage of the newer agents, particularly tapinarof and roflumilast. Moreover, formulation is important. For example, foams and solutions may be easier to use on hair-bearing areas compared with other formulations. It is also important to query the patient about their experience with using different formulations and review what they like and do not like. Creams are often better tolerated simply because of cosmesis, but, in my experience, a lot of patients with plaque psoriasis view ointments to be more effective. There is no one-size-fits-all answer. Optimizing adherence comes down to simplifying the regimen, choosing 1 topical that can be used on the entire body, and using a formulation that the patient finds cosmetically acceptable.

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An important consideration is that the patient needs to see that the therapy is effective. A patient may quickly abandon a slow-acting topical, whereas a rapidly acting topical—or at least one that has measurable benefits in a short period—may engender confidence and encourage them to continue using the medicine. However, I find that if I am up front when prescribing tapinarof or roflumilast and explain that it will take at least 4 weeks of continuous use to be able to see fulsome positive effects, that softens the blow, and the patient is often willing to stick with it. You need to remind the patient that there may be a slower response, but the advantage is that these nonsteroidal agents do not have the side effects that are typically associated with long-term corticosteroid use.