Topical Prescription Therapy for Psoriasis: An Expert Position Paper on Limitations of Published Guidelines and...

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.

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.

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.

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 Limitations of published guidelines include susceptibility to becoming outdated, lack of individualized care, variability in development, and incomplete reflection of evolving practice patterns or individual patient circumstances.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.

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.

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.