Topical Prescription Therapy for Psoriasis: An Expert Position Paper on Limitations of Published Guidelines and Treatment Selection With Updated Recommendations

J Clin Aesthet Dermatol. 2026;19(6):15–21.

by Joshua Burshtein, MD; Danny Zakria, MD, MBA; Tina Bhutani, MD; Christopher G. Bunick, MD, PhD; Melissa Costner, MD; Douglas DiRuggiero, DMSc, MHS, PA-C; Adam Friedman, MD; Alexandra K. Golant, MD; Eingun James Song, MD; Linda Stein Gold, MD; Melodie Young, MSN, A/GNP-C; and James Q. Del Rosso, DO

Dr. Burshtein is with the Department of Dermatology, University of Illinois Chicago, Chicago, Illinois. Drs. Zakria and Golant are with the Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York. Dr. Bhutani is with the Department of Dermatology, University of California, San Francisco, San Francisco, California. Dr. Bunick is with the Department of Dermatology, Yale School of Medicine, New Haven, Connecticut. Dr. Costner is with the Department of Dermatology, UT Southwestern Medical Center, Dallas, Texas. Dr. DiRuggiero is with Skin Cancer and Cosmetic Dermatology Center, Rome, Georgia. Dr. Friedman is with the Department of Dermatology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia. Dr. Song is with Frontier Dermatology, Mill Creek, Washington. Dr. Stein Gold is with Dermatology Clinical Research, Henry Ford Health System, Detroit, Michigan. Ms. Young is with Mindful Dermatology, Dallas, Texas. Dr. Del Rosso is with JDR Dermatology Research, Las Vegas, Nevada.

FUNDING: Medical writing was supported by Arcutis Biotherapeutics. Arcutis was not otherwise involved in the preparation and content of the manuscript, which was determined solely by the authors. Authors 3-11 received no form of compensation, including financial, for the preparation and writing of this manuscript. Authors 1 (J.B.) and 2 (D.Z.) received financial compensation based on time dedicated to writing of the manuscript. The final manuscript content was determined solely by the authors.

DISCLOSURES: Drs. Burshtein and Zakria have no conflicts relevant to the contents of this article. Dr. Bhutani has received research funding from Amgen, Castle, CorEvitas, Novartis, Pfizer, and Regeneron. She has served as an advisor for AbbVie, Apogee, Arcutis, Aslan, Boehringer Ingelheim, Bristol Myers Squibb, Castle, Dermavant, Galderma, Incyte, Janssen, LEO Pharma, Lilly, Oruka, Pfizer, Novartis, Sanofi, Sun Pharmaceuticals, Takeda, Taxa, and UCB. She is a speaker for AbbVie, Amgen, Arcutis, Bristol Myers Squibb, Dermavant, Galderma, Janssen, LEO Pharma, Lilly, Mindera, Ortho, Sanofi, and UCB. Dr. Bunick has served as an investigator and/or consultant for AbbVie, Almirall, Alumis, Amgen, Apogee, Arcutis, Botanix, Castle Biosciences, Connect BioPharma, Daiichi Sankyo, Dermavant, Disc Medicine, EPI Health/Novan, Galderma, Incyte, LEO Pharma, Lilly, Novartis, Ortho Dermatologics, Palvella, Pfizer, Regeneron, Sanofi, South Beach Symposium, Sun Pharmaceuticals, Takeda, Timber, Teladoc, Triveni, UCB, and Veradermics. Dr. Costner has served on the speaker bureau for AbbVie, Arcutis, Incyte, Lilly, Organon, and Sanofi; on ad boards for AbbVie, Arcutis, Johnson & Johnson, Lilly, Novartis, Organon, and Sanofi. Dr. DiRuggiero has served as an advisory board and/or speakers bureau member for AbbVie, Amgen, Arcutis, Dermavant, Galderma, Incyte, Johnson & Johnson, Lilly, Novartis, Sanofi/Regeneron, and UCB. Dr. Friedman has served as a consultant, advisor, and/or speaker for and/or received grants from AbbVie, Arcutis, Galderma, Hoth Therapeutics, Incyte, Johnson & Johnson, Kenvue, L’Oréal, La Roche Posay, LEO Pharma, Lilly, Microcures, Mino Labs, Novartis, Pfizer, Sanofi-Regeneron, Takeda, UCB, and Zylo Therapeutics. Dr. Golant declares personal fees from AbbVie, Amgen, Apogee Therapeutics, Arcutis, Boehringer Ingelheim, Bristol Myers Squibb, Dermavant, Galderma, Incyte, Janssen, LEO Pharma, Lilly, Oruka Therapeutics, Pfizer, Regeneron, Sanofi, and Takeda Pharmaceuticals. Dr. Song has been an investigator, consultant, and/or speaker for AbbVie, Acelyrin, Alphyn, Alumis, Amgen, Apogee, Arcutis, ASLAN, Boehringer Ingelheim, Bristol Myers Squibb, Castle Biosciences, CorEvitas, Dermavant, DermBiont, Galderma, Incyte, Janssen, LEO Pharma, Lilly, MoonLake, Novartis, Pfizer, Regeneron, Sanofi Genzyme, Sun Pharmaceuticals, TARGET PharmaSolutions, TIMBER, UCB, and Zura Bio. Dr. Stein Gold has served as an advisor, consultant, speaker, or investigator for Amgen, AbbVie, Almirall, Arcutis, Bausch Health/Valeant, OrthoDermatologics, Bristol Myers Squibb, Cara, Organon, Dermira, Incyte, Janssen Pharmaceuticals, LEO Pharma, Lilly, Galderma, Novartis, Sun Pharmaceuticals, Pfizer, Sanofi, Regeneron, and UCB. Ms. Young has been a research investigator, advisor and/or speaker for AbbVie, Alumis, Arcutis, Bristol Myers Squibb, Janssen, Lilly, Novartis, Organon, Oruka, Pfizer, Roche, Sanofi, Sun Pharmaceuticals, Takeda, UCB, and Veraderics. Dr. Del Rosso is a consultant/advisor, research investigator, and/or speaker for AbbVie, Almirall, Alumis, Amgen, Apogee, Arcutis, Bausch Health/OrthoDermatologics, Beiersdorf, Biofrontera, Bluefin, Blueprint Medicines, Botanix, Bristol Myers Squibb, Cara, Celgene, Ferndale, Galderma, Incyte, Janssen, Johnson & Johnson, LaRoche Posay, LEO Pharma, Lilly, L’Oréal, MC2 Therapeutics, MoonLake, Novan, Oruka, Pelthos Therapeutics, Pfizer, Regeneron, Sanofi, Sun Pharma, Takeda, Trevi, UCB, and Verrica.

ABSTRACT: BACKGROUND: Clinical guidelines serve as summaries of available treatment options, often coupled with specific recommendations related to treatment selection, and have benefits and limitations. Guidelines often influence how individual clinicians and/or third-party payors select treatments for patients. OBJECTIVE: This expert position article reviews the intent of treatment guidelines, discusses guidelines for topical psoriasis therapies, and provides recommendations for guideline updates. The recommended approaches discussed in this article by the authors align directly with therapy selection made when clinicians incorporate shared decision-making with the individual patient. METHODS: A comprehensive literature search of PubMed, Scopus, and Google Scholar was completed on May 20, 2025, using a combination of keywords “psoriasis,” “topical,” “treatments,” “adverse effects,” and “clinical guidelines” along with Boolean term “AND” for English-language original research articles, systematic reviews, narrative reviews, and meta-analyses without date restrictions. The expert position presented by the authors is limited to a discussion of topical therapies for psoriasis. RESULTS: Clinical guidelines are developed with the overall intent of enhancing healthcare quality; however, they are not designed to constrain or supplant the clinician’s decisions in determining a suitable treatment for an individual patient. Limitations of published guidelines include susceptibility to becoming outdated, lack of individualized care, variability in development, and incomplete reflection of evolving practice patterns or individual patient circumstances. The results of this review of clinical guidelines reflect the authors’ conclusions from analysis of the published data, including the evaluation of how they may influence treatment selection for psoriasis by clinicians. Regarding topical psoriasis treatment, initial therapy should be supported by Food and Drug Administration (FDA) approval and labeling. These include topical roflumilast, tapinarof, topical corticosteroids, and vitamin D analogs in the same category, with no utilization management criteria dictating order of use. LIMITATIONS: The results of this review are limited by the inability to include literature that was not present in the databases queried. As this review is based on previously published data, there is potential for reporting and publication bias. CONCLUSION: This expert position paper encourages decision-makers to work with clinicians in providing individualized, accessible care, rather than relying solely on treatment guidelines to establish utilization management protocols. It is crucial that clinical guidelines evolve in a timely manner to reflect new therapeutic developments. Following FDA-approved indications, step-through requirements for any topical psoriasis therapy need to be abandoned, as this results in delays in treatment for the patient, unnecessary healthcare costs, and wasted use of healthcare resources. KEYWORDS: Expert position, psoriasis, guidelines, limitations, topical therapies, treatment selection

Introduction

Psoriasis is a chronic inflammatory skin disease that has substantial physical and psychosocial burden on individuals of all ages.^1–4 The severity of psoriasis can range from mild to severe, and there are a variety of topical and systemic treatment options available with numerous recent advancements.⁵ Based on detailed evaluation, clinicians have a responsibility to the patient to recommend what they determine to be the most optimal treatment while providing appropriate education on the available therapies. Shared decision-making, built upon clinical expertise and patient preferences, is essential to ensuring that treatment plans are both based in evidence and aligned with the individual’s goals and circumstances.⁶ Clinical recommendations are shaped by multiple variables, including disease severity and location, clinician’s experience, information in Food and Drug Administration (FDA)-approved labeling (if applicable), data from peer-reviewed literature, access considerations, and patient preferences. Clinicians should recommend treatment options that provide the best course of action based on their professional assessment of the individual patient’s needs.

Clinical guidelines serve as summaries of available treatment options and suggestions based on a comprehensive review of the literature within a specific timeframe; however, they are not intended to mandate decision-making for the individual patient.^5,7 There are a variety of published treatment guidelines, including topical, oral, injectable, and/or physical modalities.^8–11 This expert position is limited to a discussion of topical therapies for psoriasis. The American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) last updated their topical therapy guidelines for psoriasis in 2021 and therefore do not include more recent literature for novel FDA-approved treatment options.^5,12,13 Guidelines from international committees have also been remained stagnant over various prolonged durations of time.^14–16 This is an inherent limitation with published treatment guidelines, which are not updated frequently enough to reflect recognized advances in therapy, including FDA-approved treatments.

Over the past several years, there have been substantial advances in the topical therapeutic landscape for psoriasis. A recent expert consensus panel provided recommendations on the role of advanced targeted topical therapies in the treatment of inflammatory skin diseases as an alternative or adjunct to topical corticosteroids (TCS) and advised that they be available as options for initial treatment.¹⁷ This paper will review the intent of treatment guidelines, discuss the AAD/NPF guidelines for topical psoriasis therapies, and provide recommendations for guideline updates in order to inform real-world clinical practice decisions and improve patient outcomes.

Intent of Treatment Guidelines

Clinical treatment guidelines can serve an important role in enhancing healthcare quality and patient outcomes by supporting clinicians in making evidence-based decisions that they can adjust to their patients’ needs.^18,19 Guidelines are intended to inform clinicians of the armamentarium of therapies available for practicing medicine with evidence-based criteria defined in the publication and, as such, have the potential to reduce unwarranted practice variation and enhance translation of research into clinical practice.^18,20,21 However, guidelines are not mandates. Rather, they are overall recommendations that are not without limitation; concerns include the variability in their reliability, the availability of high-quality evidence, their susceptibility to becoming outdated, and their insufficient alignment with individual patient needs and values as determined in collaboration with their treating clinician.^18,22,23 In addition, the processes by which clinical guidelines are developed, revised, and applied differ substantially across various therapeutic areas and medical specialties. Further, some previously published guidelines have been applied beyond their intended scope, resulting in restrictions that limit clinicians’ therapeutic decision-making. They are being used for purposes such as informing institutional policy, insurance coverage, deriving quality-of-care criteria, and medicolegal liability standards.^19,20,24

Clinical guidelines are an overview of potential treatment options and recommendations based on a global review of the literature, but they are not the only source of information used for decision-making for the individual patient.^20,25,26 While clinical guidelines serve as a framework for evidence-based decision-making, they are not designed to constrain the clinician’s discretion in determining the most suitable treatment for an individual patient at the time of evaluation.^18,20,26 Guidelines also do not inherently allow for individualization of care, which is ultimately determined collectively by the clinician and the patient.^18,20,26 When a clinical therapeutic decision is made for a patient, clinicians should consider the patient’s clinical presentation and individual context, verifying prescription information using authoritative sources, and assessing for contraindications, warnings, and potential drug interactions.

Indeed, national and international guidelines consistently state disclaimers for the application of their guidelines to clinical practice. For example, the National Comprehensive Cancer Network (NCCN) publishes guidelines with the intent to advance the quality of cancer care around the world and are updated at the time new key data are available.²⁷ Even with the infrastructure and rigor applied by the NCCN, the organization includes a disclaimer that it is expected that independent medical judgment is applied in the context of individual clinical circumstances to determine a specific patient’s care or treatment.²⁸ Another example is the American Heart Association guidelines for heart failure, which state that the intent is to define practices meeting the needs of most patients but should not replace clinical judgment.²⁹ Additionally, the joint AAD/NPF guidelines for the management and treatment of psoriasis with topical treatments provides a disclaimer for the appropriate interpretation of the guidelines.⁵ The disclaimer clarifies that the guidelines do not establish a specific standard of care or encompass all appropriate care methods. It states the final decision on suitable treatment lies with the treating clinician and the patient, considering the disease presentation and individual patient circumstances.⁵ These clinically relevant disclaimers allow for additional literature, topical treatment options, and clinician experiences to be incorporated into the treatment decision-making.

Further, though published standards from organizations such as the National Academy of Medicine are available for guideline development,^30,31 there remains variability among guidelines with respect to: 1) regularity of assessment and updates, 2) quality of individual studies and systematic reviews, and 3) specificity of treatment algorithms provided and strength of data used to inform them (ie, Delphi is a vote).^19,20 Clinicians writing guidelines may also have differing levels of real-world experiences with medications that can introduce preferences for particular recommendations, and mandates on chosen level of evidence used for publication are variable. Notably, guidelines in dermatology are updated less frequently than other therapeutic areas (ie, NCCN Guidelines are updated at least annually³²), with some AAD guidelines being published every 8 to 10 years (ie, acne, atopic dermatitis).^33,34

When treatment guidelines and product labels are developed, they are based on the best available evidence and regulatory standards at the time of their formation.³⁵ However, they may not fully reflect emerging clinical data, evolving practice patterns, or individual patient circumstances. As such, when there is substantial literature and clinical rationale present, off-label use of medications is often supported.³⁶ To ensure timely access to appropriate care, off-label uses may deserve an expedient appeal process when deemed medically necessary by the treating physician.

One recent introduction into guidelines is consideration of cost.³⁷ Cost considerations in guidelines are often narrowly focused on wholesale drug prices, without accounting for real-world variables such as patient copays, differences in the details of insurance coverages among patients, or access programs. This also overlooks downstream costs of delayed or suboptimal treatment, including disease progression, loss of work productivity, and increased healthcare utilization. Additionally, the financial impact of adverse events (AEs) from less effective or riskier therapies is frequently underestimated. Unbiased therapeutic recommendations within guidelines should prioritize clinical efficacy and safety, without being heavily influenced by cost considerations.

AAD/NPF Guidelines for the Topical Treatment of Psoriasis

The AAD and NPF released joint guidelines in 2021 on the management of psoriasis with topical therapy.⁵ These guidelines discuss the efficacy and AEs of various topicals, including TCS, calcineurin inhibitors, vitamin D analogs, and tazarotene as monotherapy or combination therapy for mild-to-moderate psoriasis.⁵ While these guidelines can provide a useful and consolidated framework for clinicians to reference, they have a few key limitations.

The timing and frequency of guideline updates do not coincide with newly approved treatment options and new clinical data for current treatment options. The guidelines also provide no clear statement of initial treatment or a treatment algorithm among the topical treatments for psoriasis. The intent is to provide possible treatment options and supportive data to allow decision-making by the clinician based on the context of disease presentation at the time of evaluation. Notably, these current guidelines do not include topical treatment options that were approved by the FDA within a few months after the publication of the guidelines, which include roflumilast and tapinarof. However, the guidelines note that they are not inclusive of all proper methods of care and that the ultimate judgment regarding the proper treatment resides with the treating clinician and the patient. Moreover, guidelines do not account for patient compliance, and the adherence observed in randomized controlled trials does not reflect real-world use. Poor therapeutic compliance remains one of the primary reasons topical treatments may be less effective outside of clinical trials.

The level of evidence to support the inclusion of topical calcineurin inhibitors in guidelines is limited for the treatment of psoriasis and based on studies showing its efficacy for facial and intertriginous disease.^38,39 For psoriasis not involving these special sites, a pilot study demonstrated that there was no statistically significant difference between the efficacy of tacrolimus and placebo ointment.⁴⁰ This is important as there is a need for nonsteroidal topical treatments in the management of psoriasis. According to the guidelines, TCS, especially those in class 1 or 2, should not be used for more than 4 weeks.⁵ While a repeated course can be used for flares, it is important to exercise caution due to the risk of skin atrophy, striae, folliculitis, telangiectasia, and purpura with prolonged use.

Another concern with prolonged TCS use is steroid withdrawal syndrome, also known as “red skin syndrome” or “topical steroid addiction.” This syndrome can present as skin burning and erythema after discontinuation of prolonged application of moderate- to high-potency TCS.⁴¹ A systematic review found that TCS withdrawal resulted from prolonged, inappropriate, and frequent use of moderate- to high-potency TCS primarily on the face and genital area.⁴² While patients can be counseled on the appropriate use of TCS to avoid these AEs, accidental misuse is not uncommon. This has prompted regulatory statements from different agencies, including the Medicines and Healthcare products Regulatory Agency in the United Kingdom and the Government of Canada, on the importance of using TCS appropriately and for short periods of time and as prescribed.^43,44 Additionally, the National Eczema Association provided clinical guidelines on the appropriate use of TCS to avoid AEs, including steroid withdrawal syndrome.⁴⁵ These risks and warnings highlight the need for safe and effective nonsteroidal options to manage chronic inflammatory conditions.

Recommendation for Guideline Updates and Real-World Clinical Practice

Clinical guidelines should be directed by real-world practice circumstances and shared decision-making between clinicians and patients. As the intention of guidelines is to inform evidence-based care, real-world practices should be a consideration in the formulary decision-making process for providing access and creating utilization management terms. In the clinical setting, these considerations may include description of disease severity based on the clinicians’ assessment (described as Investigator’s Global Assessment [IGA] in clinical trials) in place of Psoriasis Area and Severity Index (PASI) scoring, which is a research parameter used specifically in clinical trials for evaluating psoriasis severity.^46,47 Historically, the global severity designations of mild, moderate, and severe have been used in clinical trials, and these have been comfortably adapted by clinicians for documentation in real-world clinical practice. More recently, the International Psoriasis Council (IPC) and NPF have suggested the designations of “topical therapy eligible” or “systemic therapy eligible.” This is a highly relevant documentation approach in clinical practice, as this encompasses several clinically relevant factors that directly affect patients with psoriasis.^48,49 Importantly, this IPC/NPF approach expands the clinician’s assessment in clinical practice to include body surface area (BSA) affected by psoriasis, IGA, and anatomic locations of psoriasis involvement, along with patient-reported outcomes such as specific quality of life measures (ie, pain, psychosocial effects) and the impact of itch.^48,49 In the real-world, clinicians also guide care decisions based on patient concerns with recommended treatments or prior used treatments, as well as individual comorbidities, the patient’s ability to understand application instructions, minimizing medication use errors, and practical patient factors (type of work, frequency of travel, etc).

As guidelines are updated infrequently, often only every several years, real-world clinical care can lag behind therapeutic advances, leading to variability in practice patterns and potentially a negative impact on patient care. For clinical guidelines to be most effective, they should optimally be treated as a living document that undergoes regular updates, incorporating not only newly approved therapies but additions to clinical evidence for efficacy and safety of existing treatments.^50,51

With respect to topical treatment of psoriasis, initial topical therapy options should comprise options supported by FDA approval and labeling. These include topical roflumilast, tapinarof, TCS, and vitamin D analogs in the same category (and the combination options), with no utilization management criteria separating or dictating the order of use. Neither roflumilast nor tapinarof has restrictions on usage for psoriasis location, severity, or duration.^52,53 On the other hand, there are well-documented AEs after inappropriate TCS use. The AEs with TCS include skin atrophy, cracking/fissuring, striae, telangiectasias, bleeding, pain/stinging sensation, perioral dermatitis, acne, rosacea, contact dermatitis, and skin infections.^54–59 Consequently, recommended TCS use is limited overall to nonsensitive, thicker skin locations for limited amounts of time. Increasing literature also reveal systemic AEs of TCS, including the development of avascular necrosis, type 2 diabetes, adrenal suppression, and Cushing’s syndrome.^55,60–69

As there are limited randomized clinical trials with head-to-head comparative data of the topical therapies for psoriasis, clinicians decide on which therapy to use based on prior clinical experience and their judgment from available medical literature. Therefore, therapy selection should be consistent with the FDA-approved prescribing information. FDA labels for traditional topical therapies for psoriasis (TCS, vitamin D analogs) do not specify that patients must trial one therapy prior to treatment with another.^70–73 In addition, roflumilast and tapinarof were investigated as monotherapy in their clinical trials and are indicated as such in their FDA labels.^52,53

Thus, the authors believe there should not be step-through requirements for any topical therapy for psoriasis, as this can result in delays in treatment and unnecessary costs to the patient and the healthcare system. As such, if the FDA indication is used as a guide for prior treatment, TCS or vitamin D analogs should not be required as step-through for tapinarof or roflumilast. Some patients may also require both topical and systemic therapy for optimal disease management, with multiple reports of efficacy from this combination.^74–76

Call to Action

This position paper encourages decision-makers to partner with clinicians in providing individualized, accessible care, rather than relying solely on treatment guidelines to establish utilization management protocols. Imposing prior authorization or other access barriers, particularly for topical therapies for psoriasis and other chronic inflammatory skin diseases, that are inconsistent with standard of care or clinical judgment can compromise patient outcomes and lead to inefficient use of healthcare resources. Manufacturers also have a responsibility to ensure streamlined access to their therapies, including formulary approval, pharmacy availability (both retail and specialty), and patient support services.

Considerations

It is critical to hold all healthcare providers who treat psoriasis to the same high standard for patient care. It is also essential to recognize and understand the evolving landscape of compounded prescriptions, given their clinical and regulatory implications. Although certain compounding facilities may have FDA oversight,⁷⁷ the compounded formulations themselves are not FDA-approved,⁷⁸ as they have not undergone the rigorous testing required of originator products. Consequently, compounded medications should not be considered equivalent alternatives for formulary use. Furthermore, the vehicles used in compounded topical preparations are not necessarily optimized for delivery through skin, in contrast to those in FDA-approved therapies.

Conclusion

Clinical treatment guidelines can serve a vital role to assist clinicians in making treatment-related decisions, though they are subject to limitations such as becoming outdated. Guidelines have been shown to enhance clinical practice, but they are not intended to be used to mandate decision-making for the individual patient. As new FDA-approved therapies and expert consensus emerge, it is important that guidelines evolve in a timely manner to reflect these developments, particularly in the topical treatment of psoriasis. This will empower clinicians to make informed, patient-centered decisions that incorporate both the latest evidence and individual patient circumstances.

Acknowledgments

Support was provided by Arcutis for secretarial assistance only and directed at the request of the senior author (J.D.R.). This support was for reference retrieval and distribution of author-selected references and to assist with article formatting and distribution to all authors for review. No company, agency, or individual other than the authors was involved with the development and/or writing of the manuscript, including content inclusion, reference inclusion, interpretation, or modifications to the manuscript.

Author contributions

All authors participated in the development and writing of this manuscript. All of the authors reviewed and approved this manuscript. All content was selected, evaluated, included in the manuscript, and/or modified during draft evaluations, solely by the authors.

References

1. Gisondi P, Del Giglio M, Girolomoni G. Treatment approaches to moderate to severe psoriasis. Int J Mol Sci. 2017;18(11):2427.
2. Kimball AB, Jacobson C, Weiss S, Vreeland MG, Wu Y. The psychosocial burden of psoriasis. Am J Clin Dermatol. 2005;6(6):383–392.
3. Raho G, Koleva DM, Garattini L, Naldi L. The burden of moderate to severe psoriasis: an overview. PharmacoEconomics. 2012;30(11):1005–1013.
4. Burshtein J, Strunk A, Garg A. Incidence of psoriasis among adults in the United States: a sex- and age-adjusted population analysis. J Am Acad Dermatol. 2021;84(4):1023–1029.
5. 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 severity measures. J Am Acad Dermatol. 2021;84(2):432–470.
6. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361–1367.
7. Smith Begolka W, Elston DM, Beuter KR. American Academy of Dermatology evidence-based guideline development process: responding to new challenges and establishing transparency. J Am Acad Dermatol. 2011;64(6):e105–e112.
8. Reynolds RV, Yeung H, Cheng CE, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2024;90(5):1006.e1-1006.e30.
9. Eisen DB, Asgari MM, Bennett DD, et al. Guidelines of care for the management of actinic keratosis. J Am Acad Dermatol. 2021;85(4):e209–e233.
10. Kouba DJ, LoPiccolo MC, Alam M, et al. Guidelines for the use of local anesthesia in office-based dermatologic surgery. J Am Acad Dermatol. 2016;74(6):1201–1219.
11. Swetter SM, Tsao H, Bichakjian CK, et al. Guidelines of care for the management of primary cutaneous melanoma. J Am Acad Dermatol. 2019;80(1):208–250.
12. Lebwohl MG, Kircik LH, Moore AY, et al. Effect of roflumilast cream vs vehicle cream on chronic plaque psoriasis: the DERMIS-1 and DERMIS-2 randomized clinical trials. JAMA. 2022;328(11):1073–1084.
13. Lebwohl MG, Stein Gold L, Strober B, et al. Phase 3 trials of tapinarof cream for plaque psoriasis. N Engl J Med. 2021;385(24):2219–2229.
14. Canadian Psoriasis Guidelines Addendum Committee. 2016 addendum to the Canadian Guidelines for the Management of Plaque Psoriasis 2009. J Cutan Med Surg. 2016;20(5):375–431.
15. Nast A, Altenburg A, Augustin M, et al. German S3‐Guideline on the treatment of psoriasis vulgaris, adapted from EuroGuiDerm – part 1: treatment goals and treatment recommendations. J Dtsch Dermatol Ges. 2021;19(6):934–150.
16. Amatore F, Villani AP, Tauber M, Viguier M, Guillot B; Psoriasis Research Group of the French Society of Dermatology (Groupe de Recherche sur le Psoriasis de la Société Française de Dermatologie). French guidelines on the use of systemic treatments for moderate‐to‐severe psoriasis in adults. J Eur Acad Dermatol Venereol. 2019;33(3):464–483.
17. Burshtein J, Chovatiya R, Golant A, et al. Risks of topical corticosteroid therapy and role for advanced targeted topical treatments for inflammatory skin diseases: an expert consensus panel. Dermatol Online J. 2025;31(1).
18. Guerra-Farfan E, Garcia-Sanchez Y, Jornet-Gibert M, Nuñez JH, Balaguer-Castro M, Madden K. Clinical practice guidelines: the good, the bad, and the ugly. Injury. 2023;54 Suppl 3:S26–S29.
19. Yi TW, Donnellan S, Levin A. Evidence-based decision making 4: clinical practice guidelines. Methods Mol Biol. 2021;2249:455–466.
20. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999;318(7182):527–530.
21. Murad MH. Clinical practice guidelines: a primer on development and dissemination. Mayo Clin Proc. 2017;92(3):423–433.
22. Kung J, Miller RR, Mackowiak PA. Failure of clinical practice guidelines to meet institute of medicine standards: two more decades of little, if any, progress. Arch Intern Med. 2012;172(21):1628–1633.
23. Martínez García L, Sanabria AJ, García Alvarez E, et al. The validity of recommendations from clinical guidelines: a survival analysis. CMAJ. 2014;186(16):1211–1219.
24. Greenfield S. Clinical practice guidelines: expanded use and misuse. JAMA. 2017;317(6):594–595.
25. Keiffer MR. Utilization of clinical practice guidelines: barriers and facilitators. Nurs Clin North Am. 2015;50(2):327–345.
26. Morgott M, Heinmüller S, Hueber S, Schedlbauer A, Kühlein T. Do guidelines help us to deviate from their recommendations when appropriate for the individual patient? A systematic survey of clinical practice guidelines. J Eval Clin Pract. 2020;26(3):709–717.
27. Advancing quality cancer care around the globe. National Comprehensive Cancer Nerwork. 2025. Accessed 24 Jul 2025. https://www.nccn.org/docs/default-source/global/global-clinical-resources-overview.pdf?sfvrsn=efd8818a_2
28. Framework for resource stratification of NCCN Guidelines. National Comprehensive Cancer Network. Accessed 24 Jul 2025. https://www.nccn.org/global/what-we-do/nccn-framework-for-resource-stratification-of-nccn-guidelines
29. Heidenreich PA, Bozkurt B, Aguilar D, et al; ACC/AHA Joint Committee Members. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(18):e895–e1032.
30. Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines; Graham R, Mancher M, Miller Wolman D, Greenfield S, Steinberg E, eds. Clinical Practice Guidelines We Can Trust. National Academies Press; 2011. Accessed 2 April 2025. https://www.ncbi.nlm.nih.gov/books/NBK209539/
31. Institute of Medicine (US) Committee on Standards for Systematic Reviews of Comparative Effectiveness Research; Eden J, Levit L, Berg A, Morton S, eds. Finding What Works in Health Care: Standards for Systematic Reviews. National Academies Press; 2011. Accessed 2 April 2025. https://www.ncbi.nlm.nih.gov/books/NBK209518/
32. Development and update of guidelines. National Comprehensive Cancer Network. Accessed 10 Oct 2025. https://www.nccn.org/guidelines/guidelines-process/development-and-update-of-guidelines
33. Clinical guidelines. American Academy of Dermatology. Accessed 30 Jul 2025. https://www.aad.org/clinical-quality/guidelines
34. Vernooij RW, Sanabria AJ, Solà I, Alonso-Coello P, Martínez García L. Guidance for updating clinical practice guidelines: a systematic review of methodological handbooks. Implement Sci. 2014;9:3.
35. Prescribing information resources. Food and Drug Administration. Accessed 30 Jul 2025. https://www.fda.gov/drugs/fdas-labeling-resources-human-prescription-drugs/prescribing-information-resources
36. Chu B, Fleischer A Jr, Barbieri JS. The frequency of off-label prescribing in the treatment of dermatologic diseases during 2006-2015. J Am Acad Dermatol. 2020;82(2):493–495.
37. Issa NT, Bunick CG. In response to Reynolds et al’s “guidelines of care for the management of acne vulgaris.” J Am Acad Dermatol. 2024;91(4):e113–e114.
38. Lebwohl M, Freeman AK, Chapman MS, Feldman SR, Hartle JE, Henning A; Tacrolimus Ointment Study Group. Tacrolimus ointment is effective for facial and intertriginous psoriasis. J Am Acad Dermatol. 2004;51(5):723–730.
39. Freeman AK, Linowski GJ, Brady C, et al. Tacrolimus ointment for the treatment of psoriasis on the face and intertriginous areas. J Am Acad Dermatol. 2003;48(4):564–568.
40. Zonneveld IM, Rubins A, Jablonska S, et al. Topical tacrolimus is not effective in chronic plaque psoriasis: a pilot study. Arch Dermatol. 1998;134(9):1101–1102.
41. Cotter C, Burton T, Proctor A, Moss C, Flohr C. Topical steroid withdrawal syndrome: time to bridge the gap. Br J Dermatol. 2022;187(5):780–781.
42. Hajar T, Leshem YA, Hanifin JM, et al. A systematic review of topical corticosteroid withdrawal (“steroid addiction”) in patients with atopic dermatitis and other dermatoses. J Am Acad Dermatol. 2015;72(3):541–549.e2.
43. Topical steroid withdrawal reactions: a review of the evidence. Medicines and Healthcare products Regulatory Agency. 15 Sep 2021. Accessed15 Oct 2025. https://www.gov.uk/government/publications/topical-steroid-withdrawal-reactions-a-review-of-the-evidence/topical-steroid-withdrawal-reactions-a-review-of-the-evidence#discussion
44. Topical corticosteroids and the risk of topical withdrawal reactions. Health Product InfoWatch. Health Canada. 28 Jul 2022. Accessed 15 Oct 2025. https://www.canada.ca/en/health-canada/services/drugs-health-products/medeffect-canada/health-product-infowatch/july-2022.html#a6.1.1
45. Hajar T, Leshem YA, Hanifin JM, et al; (the National Eczema Association Task Force). A systematic review of topical corticosteroid withdrawal (“steroid addiction”) in patients with atopic dermatitis and other dermatoses. J Am Acad Dermatol. 2015;72(3):541–549.
46. Langley RGB, Feldman SR, Nyirady J, van de Kerkhof P, Papavassilis C. The 5-point Investigator’s Global Assessment (IGA) Scale: a modified tool for evaluating plaque psoriasis severity in clinical trials. J Dermatol Treat. 2015;26(1):23–31.
47. Feldman SR, Krueger GG. Psoriasis assessment tools in clinical trials. Ann Rheum Dis. 2005;64(suppl 2):ii65–ii68.
48. Strober BE, Blauvelt A, van de Kerkhof PCm, et al. International Psoriasis Council psoriasis disease severity reclassification: update on validity, acceptance, and implementation. J Am Acad Dermatol. 2025;93(4):1154–1157.
49. Strober B, Ryan C, van de Kerkhof P, et al. Recategorization of psoriasis severity: Delphi consensus from the International Psoriasis Council. J Am Acad Dermatol. 2020;82(1):117–122.
50. Drucker AM, Lam M, Prieto-Merino D, et al. Systemic immunomodulatory treatments for atopic dermatitis: living systematic review and network meta-analysis update. JAMA Dermatol. 2024;160(9):936–944.
51. Drucker AM, Walwyn C, Chu C, et al. Living network meta-analysis to compare nemolizumab against other available targeted systemic treatments for atopic dermatitis. Br J Dermatol. 2025;193(3):548–552.
52. ZORYVE (roflumilast) cream, 0.15%. Prescribing information. Arcutis Biotherapeutics, Inc.; 2024.
53. VTAMA® (tapinarof) cream, 1%. Prescribing information. Organon Pharmaceuticals; 2022.
54. Egeberg A, Schlapbach C, Haugaard JH, et al. Adverse events from topical corticosteroid use in chronic hand eczema — findings from the Danish Skin Cohort. JAAD Int. 2024;14:77–83.
55. Horn EJ, Domm S, Katz HI, Lebwohl M, Mrowietz U, Kragballe K; International Psoriasis Council. Topical corticosteroids in psoriasis: strategies for improving safety. J Eur Acad Dermatol Venereol. 2010;24(2):119–124.
56. Rogalski C, Haustein UF, Glander HJ, Paasch U. Extensive striae distensae as a result of topical corticosteroid therapy in psoriasis vulgaris. Acta Derm Venereol. 2003;83(1):54–55.
57. Kannan S, Khan W, Bharadwarj A, Rathore BS, Khosla PP. Corticosteroid-induced cutaneous changes: a cross-sectional study. Indian J Pharmacol. 2015;47(6):696–698.
58. Lauerma AI, Reitamo S. Contact allergy to corticosteroids. J Am Acad Dermatol. 1993;28(4):618–622.
59. Takeda K, Arase S, Takahashi S. Side effects of topical corticosteroids and their prevention. Drugs. 1988;36 Suppl 5:15–23.
60. Arya V, Sharma A, Ali M. Iatrogenic Cushing’s syndrome from topical steroid use. Eur J Rheumatol. 2022;9(2):106–107.
61. Gilbertson EO, Spellman MC, Piacquadio DJ, Mulford MI. Super potent topical corticosteroid use associated with adrenal suppression: clinical considerations. J Am Acad Dermatol. 1998;38(2 Pt 2):318–321.
62. Lawlor F, Ramabala K. Iatrogenic Cushing’s syndrome–a cautionary tale. Clin Exp Dermatol. 1984;9(3):286–289.
63. Negrini S, Murdaca G, Ferone D, Borro M. Adult iatrogenic Cushing’s syndrome induced by topical skin corticosteroid misuse. Therapie. 2019;74(5):547–549.
64. Demirsoy EO, Bilen N, Aktürk AS, Kocaoğlu Ö, Mutlu GY. Cushing’s syndrome induced by high-potency topical corticosteroids. Int J Dermatol. 2014;53(1):e20-22.
65. Abtahi-Naeini B, Nasri P, Afshar K, Nouri N. Complicated iatrogenic Cushing’s syndrome induced by topical clobetasol propionate in a child with psoriasis: a case report and review of the literature. J Med Case Reports. 2024;18(1):602.
66. Reichert-Pénétrat S, Tréchot P, Barbaud A, Gillet P, Schmutz JL. Bilateral femoral avascular necrosis in a man with psoriasis: responsibility of topical corticosteroids and role of cyclosporine. Dermatology. 2001;203(4):356–357.
67. Kane D, Barnes L, Fitzgerald O. Topical corticosteroid treatment: systemic side-effects. Br J Dermatol. 2003;149(2):417.
68. Andersen YMF, 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(6):1095–1103.
69. Lam LH, Sugarman JL. Adrenal suppression with chronic topical corticosteroid use in psoriasis patients. J Drugs Dermatol. 2016;15(8):945–948.
70. Kenalog Cream (Triamcinolone Acetonide Cream) 0.025%, 0.1%, and 0.5%. Prescribing information. Apothecon; 1994. Accessed 10 Aug 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/pre96/011601s036lbl.pdf
71. WYNZORA cream (calcipotriene and betamethasone dipropionate). Prescribing information. MC2 Therapeutics Inc; Jul 2020. Accessed10 Aug 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/213422s000lbl.pdf
72. Temovate® E (clobetasol propionate) cream, 0.05%. Prescribing information. PharmaDerm; Nov 2012. Accessed 10 Aug 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020340s007lbl.pdf
73. Dovonex® (calcipotriene) cream and ointment, 0.005%. Prescribing information. LEO Laboratories; March 2015. Accessed 10 Aug 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/020273s013,020554s012lbl.pdf
74. Abdin R, Kircik L, Issa NT. First use of combination oral deucravacitinib with tapinarof cream for treatment of severe plaque psoriasis. J Drugs Dermatol. 2024;23(3):192–194.
75. Yatsuzuka K, Muto J, Kohri N, et al. Complete resolution of residual psoriasis by adding tapinarof cream to tildrakizumab: a case report. J Dermatol. 2025;52(8):e711–e713.
76. Issa NT, Wang J, Hanly A, et al. Structural insights: what makes some PDE4 inhibitors more effective in inflammatory dermatoses. J Clin Aesthetic Dermatol. 2025;18(7):18–21.
77. Registered outsourcing facilities. US Food and Drug Administration. 29 Jul 2025. Accessed 15 Aug 2025. https://www.fda.gov/drugs/human-drug-compounding/registered-outsourcing-facilities
78. Human drug compounding. US Food and Drug Administration. Accessed 15 Aug 2025. https://www.fda.gov/drugs/guidance-compliance-regulatory-information/human-drug-compounding