A potent, triple-combination topical preparation specifically formulated for the treatment of chronic, stable plaque psoriasis, particularly in the Indian context where cost-effectiveness and efficacy are paramount. This combination leverages the synergistic effects of keratolysis (Salicylic Acid), anti-proliferative and anti-inflammatory action (Dithranol), and anti-pruritic, anti-inflammatory, and anti-proliferative effects (Coal Tar) to manage thick, scaly psoriatic plaques. It is a cornerstone of the Ingram regimen (modified for short-contact therapy) and is primarily used in hospital-based or supervised outpatient settings due to its staining and irritation potential.
Adult: Apply a thin layer ONLY to the psoriatic plaques once daily. STRICT SHORT-CONTACT THERAPY is recommended: Apply, leave on for 10-30 minutes (as tolerated and prescribed), then wash off thoroughly with lukewarm water. Duration of contact is titrated upwards based on tolerance (starting from 10 mins).
Note: 1. Wear disposable gloves during application. 2. Apply precisely to the plaque, avoiding surrounding normal skin. 3. Use a spatula, not fingers, to remove ointment from the container to prevent contamination and staining. 4. After prescribed contact time, wash off thoroughly. 5. Wash hands immediately after application (even with gloves). 6. Use old, dark-colored towels and bed linen. 7. Do not apply to broken or inflamed skin. 8. Protect treated areas from sunlight (photosensitivity with Coal Tar).
The combination works synergistically. Salicylic Acid acts as a keratolytic, breaking down intercellular keratinocyte adhesions in the stratum corneum, facilitating the penetration and efficacy of Dithranol and Coal Tar, and reducing scale. Dithranol (Anthralin) inhibits mitochondrial respiration and enzyme activity (like glucose-6-phosphate dehydrogenase), reduces DNA synthesis, and induces apoptosis in hyperproliferative keratinocytes. It also modulates immune responses by inhibiting neutrophil migration and reducing IL-6 and IL-8. Coal Tar is a complex mixture that reduces epidermal DNA synthesis and mitotic activity, has anti-pruritic effects, and suppresses inflammation, possibly by inhibiting the lipoxygenase pathway.
Pregnancy: Category C (US FDA). Animal reproduction studies have not been conducted. Systemic absorption is low with proper use, but salicylates are known teratogens in high doses. Dithranol and coal tar data are limited. Use only if clearly needed and potential benefit justifies potential risk to the fetus. Avoid application to large areas or under occlusion.
Driving: No effect on driving ability. However, if severe irritation occurs, it may cause distraction.
| Other Topical Salicylic Acid Preparations | Increased risk of systemic salicylate absorption and toxicity. | Major |
| Topical Tretinoin, Benzoyl Peroxide, or other irritants | Severe cumulative skin irritation and dermatitis. | Major |
| Methotrexate | Increased risk of hepatotoxicity (theoretical with coal tar). | Moderate |
| Warfarin and other Oral Anticoagulants | Salicylic acid absorption may potentiate anticoagulant effect, increasing INR and bleeding risk. | Major |
| Oral Hypoglycemics (Sulfonylureas) | Salicylates may potentiate hypoglycemic effect. | Moderate |
| Systemic Corticosteroids | Reduced efficacy of Dithranol due to anti-inflammatory effect masking irritation, a key guide for therapy. | Moderate |
| Photosensitizing Drugs (e.g., Tetracyclines, Fluoroquinolones) | Additive photosensitivity risk with Coal Tar. | Moderate |
Same composition (Salicylic Acid (1.15% w/w) + Dithranol (1.15% w/w) + Coal Tar (5.3% w/w)), different brands: