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Aryl Hydrocarbon Receptor (AhR) Agonist Pregnancy: Avoid — animal studies showed no teratogenicity but insufficient human data; limit use in pregnancy unless clearly necessary

Tapinarof

Brand names: Vtama

Adult dose

Dose: 1% cream applied once daily to affected areas
Route: Topical
Frequency: Once daily
Max: No formal maximum; apply to affected areas only
Plaque psoriasis (adults); non-steroidal mechanism; apply thin layer to plaques; avoid eyes, mouth, vagina; can be used on any body site including face and intertriginous areas

Paediatric dose

Dose: Not established N/A/kg
Route: N/A
Frequency: N/A
Max: N/A
Not licensed in paediatrics; trials in adolescents ongoing

Dose adjustments

Renal

No systemic dose adjustment — topical

Hepatic

No systemic dose adjustment — topical

Paediatric weight-based calculator

Not licensed in paediatrics; trials in adolescents ongoing

Clinical pearls

  • PSOARING 1 and 2 trials (Strober et al. NEJM 2021): tapinarof 1% cream achieved PGA 0/1 in 36% vs 6% vehicle at week 12 — novel non-steroidal topical mechanism; MHRA licensed 2023 for plaque psoriasis
  • Novel AhR agonist mechanism: binds aryl hydrocarbon receptor in keratinocytes → upregulates skin barrier genes (filaggrin, loricrin) and downregulates IL-17A, IL-22, and IL-23 signalling; also has antioxidant effects via Nrf2 pathway; distinct from all existing topical treatments
  • Remittive effect: PSOARING 3 long-term extension showed disease-free intervals (remission) lasting median 4 months after stopping treatment — unique property not seen with steroids or calcineurin inhibitors; patients may not need continuous treatment
  • Folliculitis is the main tolerability concern (~23% in trials) — usually mild; treat with topical antibiotics if needed; typically does not require discontinuation; more common on trunk and intertriginous areas
  • Steroid-sparing positioning: suitable for body sites where topical steroids are limited (face, genitalia, skin folds); no HPA-axis suppression, skin atrophy, or steroid rebound — useful for patients with psoriasis in sensitive locations or steroid phobia

Contraindications

  • Known hypersensitivity to tapinarof

Side effects

  • Folliculitis (most common — up to 23%)
  • Contact dermatitis
  • Pruritus at application site
  • Headache
  • Nasopharyngitis
  • Perioral dermatitis (rare)

Interactions

  • No clinically significant drug interactions — minimal systemic absorption

Monitoring

  • PGA response at 4-8 weeks
  • Folliculitis assessment (each visit)
  • Application site reactions

Reference: BNFc; BNF 90; PSOARING 1 & 2 trials (Strober et al. NEJM 2021); PSOARING 3 long-term extension; MHRA SPC Vtama 2023; BAD Psoriasis Guideline (2017, updated 2022). Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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