What are the treatment options for psoriasis?

From the Guidelines

Psoriasis treatment should start with topical corticosteroids and vitamin D analogues for mild to moderate cases, and may progress to phototherapy or systemic treatments like methotrexate, cyclosporine, or biologics for moderate to severe cases, as recommended by the joint American Academy of Dermatology-National Psoriasis Foundation guidelines 1.

Treatment Approach

The treatment approach for psoriasis depends on the severity of the disease. For mild to moderate psoriasis, the following treatments can be used:

• Topical corticosteroids like betamethasone or clobetasol applied once or twice daily to affected areas for 2-4 weeks
• Vitamin D analogues such as calcipotriene can be used alongside steroids or independently
• Coal tar preparations and salicylic acid can help remove scales

Phototherapy and Systemic Treatments

For moderate to severe cases, the following treatments can be used:

• Phototherapy using UVB light 2-3 times weekly for 2-3 months may be effective, as supported by the guidelines of care for the management of psoriasis and psoriatic arthritis: section 5 1
• Systemic treatments include methotrexate (starting at 7.5-15mg weekly), cyclosporine (2.5-5mg/kg daily), or biologics like adalimumab, etanercept, or ustekinumab for severe cases, as recommended by the guidelines of care for the management of psoriasis and psoriatic arthritis: section 4 1

Lifestyle Modifications

Lifestyle modifications are also important in managing psoriasis, including:

• Moisturizing daily
• Avoiding triggers like stress and alcohol
• Taking short lukewarm showers
• Maintaining a healthy weight These treatments work by reducing inflammation, slowing skin cell growth, and modulating the immune system, as psoriasis results from an overactive immune response causing rapid skin cell turnover and inflammation, as noted in the British Association of Dermatologists' guidelines for biologic interventions for psoriasis 2009 1.

From the FDA Drug Label

The safety and efficacy of Enbrel were assessed in two randomized, double-blind, placebo-controlled studies in adults with chronic stable PsO involving ≥ 10% of the body surface area, a minimum Psoriasis Area and Severity Index (PASI) score of 10 and who had received or were candidates for systemic antipsoriatic therapy or phototherapy Topical corticosteroids are generally applied to the affected area as a thin film from two to three times daily depending on the severity of the condition.

Treatment of Psoriasis

• For adults with chronic stable psoriasis, etanercept (SQ) at doses of 25 mg once a week, 25 mg twice a week, or 50 mg twice a week for 3 months can be used 2.
• For topical treatment, triamcinolone acetonide (TOP) can be applied to the affected area as a thin film from two to three times daily depending on the severity of the condition 3.
• Occlusive dressing may be used for the management of psoriasis or recalcitrant conditions, but should be discontinued if an infection develops 3.

From the Research

Treatment Options for Psoriasis

• Topical therapies are the mainstay for the majority of patients who have limited or mild psoriasis, with topical vitamin D analogs and corticosteroids being the most widely prescribed psoriasis drugs 4.
• Combination therapies, such as combining topical corticosteroids with vitamin D analogues, can provide an improvement of psoriasis within 2 weeks, reaching a maximal improvement after 4 weeks in the majority of patients 5.
• Topical aryl hydrocarbon receptor modulators (tapinarof) and topical phosphodiesterase-4 inhibitors (roflumilast) have been proven effective in randomized controlled trials for psoriasis, although cost may limit their use 6.
• Topical vitamin D analogs have been added to the first-line treatment repertoire as well, either as monotherapy or in combination with topical steroids due to synergistic, complementary effectiveness 7.

Topical Therapies for Psoriasis

• Emollients, corticosteroids, vitamin D analogs, calcineurin inhibitors, dithranol, coal tar, retinoids, and keratolyics are all topical therapies available for the management of psoriasis 8.
• Optimal use of topical therapy requires an awareness of the range and efficacy of all products, and topical therapies used appropriately provide a safe and effective option for the management of psoriasis 8.
• The combination of potent and superpotent corticosteroids with vitamin D analogues is an efficacious and safe treatment option, with the two-compound products being the most practical solution 5.

Goals of Treatment

• The goal of treatment is to control the clinical symptoms of the skin, reduce systemic disease potential, and improve the patient's quality of life 4.
• The new consensus is to treat to a target of 1% or less of body surface area involvement, and innovative treatment strategies are needed to meet this goal and patients' desire to achieve clear skin 4.