Topical Psoriasis Treatments: A Dermatologist Explains Each Drug Class, Strength, Duration of Use, What Is Safe for the Face and Scalp, and When Creams Alone Are Not Enough

3 days ago

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Topical treatment is the first-line therapy for psoriasis in most patients, because about 7 in 10 people have the mild type, meaning a rash covering less than 5% of the body surface (about 5 palms) that can be controlled with topical drugs and adequate skin care. But "psoriasis cream" is not one product. It is at least 6 drug classes that work in different ways, differ in strength by dozens of times, and have different limitations. Many patients use the right class at the wrong strength, on the wrong site, or for the wrong length of time, and then conclude that "topical treatment does not work" when they have never used it correctly.

This article explains every class of psoriasis topical treatment used in Thailand, with generic names, strengths, how to apply them, how long to use them, and signs that they are or are not working, along with the precautions we see most often in the clinic, so that patients understand the drugs their doctor prescribes and know when to go back and adjust the plan. Choosing the drug and strength for each person is a decision for the doctor who examines the actual rash, because a drug in the same class may suit one site but be harmful at another.

A short summary before the details

There are 6 main classes of topical psoriasis treatment: steroids · vitamin D derivatives · combinations of the two · coal tar · salicylic acid · calcineurin inhibitors, plus minor options such as dithranol and topical retinoids.
The calcipotriol + betamethasone combination is the one clinical guidelines recommend first for rashes on the trunk, limbs and scalp, because it works faster and uses less steroid than applying the two drugs separately.
On the face, skin folds and genitals, never use strong steroids. Use a mild steroid for a short time, or tacrolimus/pimecrolimus instead.
Topical drugs need time: 2–4 weeks for steroids and 6–8 weeks for vitamin D derivatives before you can judge whether they work.
A cream that clears the rash unusually fast within a few days and then comes back worse when stopped often contains an undeclared strong steroid, which in psoriasis can trigger the generalized pustular type.
If you have applied the drug correctly for a full 8 weeks and the rash is still not controlled, or it covers more than 10% of the body surface, it is time for phototherapy or oral medication, not endlessly stronger topical drugs.

Before applying anything, know where the rash is and how thick it is

Skin at different sites absorbs drugs very differently. The eyelids and scrotum absorb steroids about 40 times more than the forearm, while the palms and soles absorb less than a tenth as much. This is why the same drug can be safe on the palms but cause permanent skin thinning on the face, and why the doctor must see the actual rash before prescribing, not prescribe from a description.

What the doctor assesses before choosing a topical treatment:

Location Trunk and limbs (thick skin that tolerates strong drugs) · scalp (needs a non-greasy form with a scale-dissolving agent) · face and skin folds (thin skin, needs mild drugs or non-steroid classes) · palms, soles and nails (very thick skin, needs the strongest drugs or other methods)
Scale thickness A rash with thick scale must have the scale removed first, otherwise the drug cannot penetrate.
Total rash area If it exceeds 10% of the body surface (more than 10 palms), topical treatment alone is usually not enough, and the large quantity needed risks whole-body side effects.
Disease phase A flaring, red, inflamed rash and a stable chronic rash call for different drugs.

All of this means that the question "which psoriasis cream is best" has no single answer, only an answer to "which is best for this kind of rash, at this site, right now."

Class 1: Topical steroids. Used correctly, the main drug; used wrongly, the cause of most problems

Topical corticosteroids reduce inflammation, slow skin cell division and relieve itch faster than any other topical drug, so they are both the most used and the most misused. The first thing to understand is that topical steroids come in strength levels that differ greatly.

Strength levels and generic names used in Thailand

Very potent clobetasol propionate 0.05% — for thick rashes on the trunk, limbs, palms, soles and scalp. Use continuously for no more than 2–4 weeks, then reduce or switch. Total amount no more than 50 grams per week.
Potent betamethasone dipropionate 0.05% · mometasone furoate 0.1% · fluocinolone acetonide 0.025% — the main drugs for the trunk and limbs. Can be used continuously for about 4–8 weeks under monitoring.
Moderate triamcinolone acetonide 0.1% · betamethasone valerate 0.1% — for thin rashes on the trunk, or as a step-down after a strong drug.
Mild hydrocortisone 1% · desonide 0.05% · prednisolone 0.5% — for the face, skin folds, genitals and young children. Use for no more than 1–2 weeks at a time.

How to use them effectively and safely

Apply a thin layer once or twice a day, only on the rash. Use the fingertip unit: the amount squeezed from the tip of the index finger to the first joint, about 0.5 grams, covers the area of 2 palms.
Ointments absorb better than creams. They suit thick, dry rashes, while creams and lotions suit moist rashes or hairy areas.
Most trunk rashes improve within 2 weeks. The scale thins first, then the redness and raised thickness fall. If nothing has moved by 4 weeks, go back and adjust; do not just keep applying.
When the rash is flat, do not stop suddenly. Switch to applying only on Saturdays and Sundays (weekend therapy) for another 4–8 weeks, or alternate with a vitamin D derivative on weekdays, to prevent relapse.

Real side effects and how to spot them

Thin skin, dilated capillaries, stretch marks from using strong drugs too long, or strong drugs on thin skin. Stretch marks are permanent.
Tachyphylaxis (loss of effect) the drug works less and less, usually after months of continuous use without a break.
Rebound after stopping the rash returns redder than before within a few days of stopping.
🔴 Generalized pustular psoriasis a serious condition that can occur when strong steroids are stopped suddenly after use over a wide area, or when a patient who has received oral or injected steroids stops them. This is the reason dermatologists do not use oral or injected steroids to treat psoriasis, even though they work fast. If you have fever, red skin all over and pustules spreading in sheets, go to a hospital immediately.
Steroid acne and secondary fungal skin infection when used too long on the face or skin folds.

Class 2: Vitamin D derivatives. Safe long-term maintenance drugs

Calcipotriol 50 micrograms per gram as cream, ointment and scalp solution, works by normalizing skin cell division and maturation. Unlike steroids, it does not thin the skin, does not cause tachyphylaxis, and can be used continuously for months to years, which makes it the main drug of the maintenance phase.

Apply a thin layer twice a day. Clear results appear at 6–8 weeks, slower than steroids but longer lasting.
Maximum amount 100 grams per week in adults, because the drug is absorbed into the bloodstream and can raise blood calcium if overused. People with kidney disease or abnormal calcium should consult a doctor first.
Irritation on the face and skin folds about 1 in 5 users get stinging and redness when it is applied on thin skin, so it is usually used only on the trunk, limbs and scalp. If you accidentally apply it on the face, wash your hands after every application.
Do not apply immediately before sun exposure or phototherapy, because UVA destroys the drug. Apply it after phototherapy.

Class 3: Calcipotriol + betamethasone combination. First choice for trunk and scalp rashes

The combination of calcipotriol 50 micrograms per gram + betamethasone dipropionate 0.5 milligrams per gram as ointment, gel and foam is classified in the clinical guidelines of many countries, including Thailand, as first-line treatment for mild to moderate plaque psoriasis, because the two drugs complement each other: the steroid reduces inflammation quickly, the vitamin D derivative controls cell division over the long term, and each drug's side effects are offset by the other.

Apply once a day only. On the trunk and limbs, use continuously for 4 weeks. On the scalp, the gel form can be used for up to 8 weeks.
Comparative studies found that the proportion of patients whose rash clearly improved within 4 weeks was about twice as high as with calcipotriol alone, and significantly higher than with betamethasone alone.
After the rash is flat, switch to applying twice a week as maintenance, which in studies could be continued for up to 1 year without skin thinning.
The maximum amount remains 100 grams per week, and it must still not be used on the face and skin folds because it contains a strong steroid.
Scalp gel form: apply to dry scalp at bedtime and wash out in the morning. You do not need to remove the scale first if it is not very thick.

Class 4: Coal tar. An old drug that still works for chronic rashes

Coal tar at 2–10% concentration as ointment, cream, shampoo and solution slows skin cell division and relieves itch. It has more than a century of use and remains in clinical guidelines for stable chronic rashes and scalp psoriasis.

Apply once or twice a day. The effect is gradual, becoming clear at 4–8 weeks, and it can be used for a long time without thinning the skin.
Its limitations are a strong smell and staining of clothes and bedding, and it makes skin more sensitive to light, so it is usually applied at bedtime and washed off in the morning.
Coal tar shampoo works well on the scalp. Apply over the whole scalp, leave for 5–10 minutes before rinsing, 2–3 times a week.
Do not use on a rash that is very red and inflamed or has pustules, because it will irritate and cause a flare.

Class 5: Salicylic acid. A scale remover that lets other drugs penetrate

Salicylic acid 3–6% for general skin and up to 10% for palms and soles, is a keratolytic (scale-dissolving) drug. It does not treat the disease directly, but a rash with thick scale will not respond to other drugs at all until the scale is thinner, so it is often used together as the first step.

Apply once or twice a day for about 1–2 weeks, until the scale clearly thins, and then the main drug can work.
It often comes ready-mixed with a steroid, or with coal tar in a scalp oil.
Do not apply over more than 20% of the skin, and do not use in young children, because it can be absorbed into the body and cause salicylate toxicity.
Do not apply before UVB phototherapy, because it blocks the light from reaching the skin.

Class 6: Tacrolimus and pimecrolimus. Drugs for the face, skin folds and genitals

Tacrolimus 0.03% and 0.1% and pimecrolimus 1% are calcineurin inhibitors. They reduce inflammation through immune cells without thinning the skin, so they are the main choice for psoriasis on thin skin where strong steroids cannot be used and calcipotriol irritates: the face, eyelids, skin folds, armpits, groin, under the breasts and the genitals.

Apply a thin layer twice a day. Results appear at 2–4 weeks, and they can be used continuously for several months.
This is off-label use (the registered indication is atopic dermatitis), and the doctor will explain this before prescribing.
The main side effect is burning in the first week, which usually goes away by itself, and you should protect the skin from the sun while using them.
Not suitable for thick rashes on the trunk, because they penetrate thick scale poorly.

Minor options: Dithranol, topical retinoids, and new drugs on the way

Dithranol (also called anthralin) 0.1–2% is used as short-contact therapy: apply to the rash, leave for 10–30 minutes, then wash off, once a day. It works well for thick chronic rashes and does not cause tachyphylaxis, but it stains surrounding skin and clothing purple-brown. It is now used less because of the inconvenience.
Tazarotene 0.05–0.1% is a topical retinoid, used once a day at night, often together with a steroid to reduce irritation. It must not be used in pregnant women. Availability in Thailand is limited.
New non-steroid drugs that can be applied to every site including the face and skin folds, such as topical PDE4 inhibitors and AhR agonists, began use abroad in 2022 but were not yet sold in Thailand at the time of writing.
Urea 10–20% and moisturizers are not treatments but the foundation that must be used every day alongside every class, because well-moisturized skin has less scale, less itch and absorbs drugs better. Apply twice a day to the whole body, not only on the rash.

Psoriasis topical treatments by site: what to use where

Trunk, arms, legs

First step: the calcipotriol + betamethasone combination once a day for 4 weeks, or a strong steroid once or twice a day for 2–4 weeks.
If scale is thick: salicylic acid 3–6% first for 1–2 weeks.
Maintenance: calcipotriol alone twice a day, or the combination twice a week.

Scalp

Thick scale: scalp oil with salicylic acid applied overnight, then wash with coal tar shampoo.
Treatment: the calcipotriol + betamethasone combination gel applied at bedtime and washed out in the morning for up to 8 weeks, or clobetasol 0.05% shampoo/solution left on for 15 minutes before rinsing, once a day, for no more than 4 weeks.
Avoid picking at scale and washing with hot water, because friction triggers rash along the line of injury (Koebner phenomenon).

Face, skin folds, genitals

Tacrolimus 0.1% or pimecrolimus 1% twice a day as the mainstay.
If very inflamed: a mild steroid such as hydrocortisone 1% or desonide 0.05% once or twice a day for no more than 1–2 weeks, then switch back.
Do not use clobetasol, betamethasone or mometasone in this area, and do not use calcipotriol on the eyelids.

Palms, soles

Very thick skin: clobetasol 0.05% ointment twice a day together with salicylic acid 6–10% and nighttime occlusion as advised by the doctor.
This site responds slowest to topical treatment and often needs to be combined with localized phototherapy or oral medication.

Nails

Topical drugs penetrate the nail poorly. A strong steroid with calcipotriol applied at the nail base and under the nail tip once a day for 3–6 months may help partially, but nail psoriasis that affects daily life usually needs local injections or oral medication.

What to do when topical treatment is not improving things

Before concluding that the drug does not work, go through this list in order, because these causes are more common than the drug truly being unsuitable.

It is not time yet. Steroids need 2–4 weeks; calcipotriol and coal tar need 6–8 weeks.
The scale is still thick. The drug does not penetrate; the scale must be dissolved first.
Not applying enough. Most patients apply about half of what they should. Use the fingertip unit as a guide.
Unsuitable form. A cream on a dry thick rash penetrates less well than an ointment.
A trigger is still present. Throat infection, scratching or friction, certain drugs such as beta-blocker blood pressure drugs, lithium, antimalarials, and alcohol and cigarettes make the rash resistant to every treatment.
It may not be psoriasis. A rash that does not respond to steroids at all, or improves and then spreads in rings, must be distinguished from fungal skin infection, seborrheic dermatitis, lichen planus and cutaneous lymphoma, which sometimes requires a biopsy. We explain how to tell them apart in the article What causes psoriasis, and how to tell it from seborrheic dermatitis and fungal infection

If you have gone through the whole list and it is still uncontrolled after 8 weeks, that is the indication to step up treatment, not to increase the strength of topical drugs.

When topical treatment alone is not enough

The indications dermatologists use to decide to add whole-body treatment are:

The rash covers more than 10% of the body surface, or the severity score is moderate to severe.
Rash at sites that affect life greatly even when the area is small, such as the palms, soles, nails, face and genitals, where topical treatment does not work.
Joint pain, swollen joints, sausage-like swollen fingers, or morning back pain, which point toward psoriatic arthritis that topical drugs do not help and which, left alone, causes permanent joint damage. Read more at Psoriatic arthritis: warning signs that need prompt evaluation
A pustular or whole-body red rash, which is an emergency.

Next steps in the order actually used

Narrowband ultraviolet B (narrowband UVB) phototherapy 2–3 times a week for 20–30 sessions, safe for most patients including pregnant women, available at hospitals and specialized institutes that have the equipment.
Traditional oral drugs methotrexate once a week at 7.5–25 milligrams with folic acid, needing blood tests to monitor the liver and bone marrow · acitretin 25–50 milligrams per day, not allowed in women of childbearing age who may become pregnant within 3 years · cyclosporine 2.5–5 milligrams per kilogram per day, used short-term for no more than 1–2 years because it affects the kidneys and blood pressure — details in Methotrexate for psoriasis: dose and monitoring and Cyclosporine: an immunosuppressant for severe psoriasis
Newer small-molecule drugs such as oral PDE4 inhibitors, which do not need blood-test monitoring. Read at PDE4 inhibitors for psoriasis
Injectable biologics that act specifically on the inflammatory molecules IL-17, IL-23 or TNF give nearly clear skin in most patients. Some are now covered under the government health scheme when criteria are met, and must be received through a hospital with dermatologists and a monitoring system.

Where to see a doctor, and how to choose

Psoriasis is a chronic disease that needs the same regular doctor who sees your rash continuously over years. Choosing where to be treated should therefore be based on continuity and expertise, not one-time convenience.

A specialist dermatologist is who should look after psoriasis from the first diagnosis, because the disease is often misdiagnosed as a fungal infection or allergic rash, and choosing topical strength by site requires experience. You can verify dermatology board certification through the Medical Council of Thailand search system.
Government hospitals with a dermatology department, or the Institute of Dermatology suit moderate to severe psoriasis that needs phototherapy, oral drugs requiring blood tests, or biologics under the health scheme. The limitation is long waits and often seeing a different doctor each time.
A dermatology specialty clinic suits mild to moderate psoriasis controlled with topical and basic oral drugs. It offers continuity with the same doctor, fast appointments, and referral to a hospital when biologics are needed. The condition is that it must be a verifiable specialist dermatologist, not a general aesthetic clinic.
What to step away from is any place that offers injected or oral steroids, drug packs, unlabeled creams that clear the rash in a few days, or a guarantee of cure, because with current knowledge psoriasis can be brought under control but has no permanent cure, and sudden stopping of steroids in that way is a leading cause of generalized pustular psoriasis that requires hospital admission.

For people in Samut Prakan or the Bangna area, having a specialist dermatologist near home who can follow you continuously every 4–8 weeks while the medication is adjusted, and refer you to a hospital when necessary, is a model that keeps treatment uninterrupted, which determines long-term results more than the name of any single drug.

Frequently asked questions about psoriasis topical treatments

Which psoriasis topical treatment is best?

There is no single best one for everyone, because skin at different sites absorbs drugs dozens of times differently. For thick rashes on the trunk, limbs and scalp, clinical guidelines list the calcipotriol and betamethasone dipropionate combination applied once a day as the first choice, because it works better than the separate drugs at 4 weeks and can be continued for maintenance. For the face, skin folds and genitals, the suitable choice is tacrolimus or pimecrolimus. For the palms and soles, a very potent steroid with salicylic acid is needed. So the question to ask the doctor is not "which is best" but "which is for this rash of mine, and how long should I use it before we reassess."

Can I buy psoriasis topical treatments myself at a pharmacy?

Some classes can be bought from a pharmacist, such as mild to moderate steroids, coal tar, salicylic acid and moisturizers, but the most effective drugs, calcipotriol and the combinations, as well as very potent steroids and tacrolimus, should come from a doctor who sees the actual rash. The reason is not only legal: choosing the wrong strength for a site causes permanent skin thinning, and a rash thought to be psoriasis may be a fungal infection that a steroid will make spread. If you have never been diagnosed by a dermatologist, get examined before buying drugs yourself, and avoid drug packs or herbal creams that do not list their ingredients.

How long can I use steroid cream for psoriasis?

It depends on the strength and the site. A very potent steroid such as clobetasol 0.05% should be used continuously for no more than 2–4 weeks and no more than 50 grams per week. A potent steroid such as betamethasone or mometasone can be used for about 4–8 weeks under monitoring. A mild steroid on the face and skin folds should be used for no more than 1–2 weeks at a time. When the rash is flat, do not stop suddenly; reduce to applying only on weekends for another 4–8 weeks, or alternate with calcipotriol. Overuse causes thin skin, dilated capillaries and tachyphylaxis, and sudden stopping after use over a wide area can trigger pustular psoriasis.

What do I use for scalp psoriasis?

If the scale is thick, start with scalp oil containing salicylic acid applied overnight and washed out with coal tar shampoo for 1–2 weeks to dissolve the scale. Then use the calcipotriol and betamethasone combination gel on dry scalp at bedtime, washed out in the morning, continuously for up to 8 weeks, or use clobetasol 0.05% shampoo or solution left on for 15 minutes before rinsing, once a day for no more than 4 weeks. In the maintenance phase, use coal tar shampoo 2–3 times a week. What makes it worse is picking at scale, combing hard and hot water, because friction triggers new rash along the line of injury. If patchy hair loss occurs or the rash spreads down the forehead, see a dermatologist.

What can I use for psoriasis on the face and skin folds?

These areas have thin skin and absorb a lot of drug. Do not use strong steroids such as clobetasol, betamethasone or mometasone, and calcipotriol often irritates. The suitable drugs are tacrolimus 0.1% or pimecrolimus 1% twice a day, which do not thin the skin and can be used continuously for several months, though they may burn in the first week and then settle by themselves. If the rash is very inflamed, a mild steroid such as hydrocortisone 1% or desonide 0.05% may be used short-term for no more than 1–2 weeks before switching back. Psoriasis in the skin folds often has no scale and is often misdiagnosed as a fungal infection or diaper rash. If antifungal drugs have not helped within 2 weeks, have a dermatologist examine it.

What should I do if topical treatment is not improving my psoriasis?

Check 6 things first: have you used it for long enough (steroids 2–4 weeks, calcipotriol 6–8 weeks), is the scale still too thick for the drug to penetrate, are you applying enough by the fingertip unit, are you using ointment for dry thick rashes, is there a trigger such as infection, certain drugs, alcohol, cigarettes or scratching, and is the rash truly psoriasis. If you have checked everything and it is still not controlled after 8 weeks, or the rash exceeds 10% of the body surface, or you have joint pain, go back to a dermatologist to consider phototherapy or oral medication. Do not raise the strength of topical drugs or enlarge the area treated yourself, and do not switch to drug packs or oral steroids.

References

Elmets CA, Korman NJ, Prater EF, et al. Joint AAD–NPF guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis. Journal of the American Academy of Dermatology.
Nast A, Smith C, Spuls PI, et al. EuroGuiDerm guideline on the systemic treatment of psoriasis vulgaris. Journal of the European Academy of Dermatology and Venereology.
Mason AR, Mason J, Cork M, Dooley G, Hancock H. Topical treatments for chronic plaque psoriasis. Cochrane Database of Systematic Reviews.
Samarasekera EJ, Sawyer L, Wonderling D, Tucker R, Smith CH. Topical therapies for the treatment of plaque psoriasis: systematic review and network meta-analyses. British Journal of Dermatology.
Menter A, Korman NJ, Elmets CA, et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. Journal of the American Academy of Dermatology.
Guidelines for the Management of Psoriasis, Dermatological Society of Thailand
Long CC, Finlay AY. The finger-tip unit — a new practical measure. Clinical and Experimental Dermatology.

Written by Dr. Patara Voravutinon, Dermatologist · Last reviewed September 21, 2026