What is the treatment for Plaque Psoriasis in primary care?

From the Guidelines

Treatment for plaque psoriasis in primary care typically begins with topical therapies, and the most recent guidelines recommend the use of topical corticosteroids and vitamin D analogs as first-line treatments. According to the joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies 1, topical therapies may be effective and sufficient for managing limited disease. The guidelines suggest that topical corticosteroids, such as betamethasone valerate 0.1% or clobetasol propionate 0.05%, can be applied once or twice daily to affected areas for 2-4 weeks to reduce inflammation and slow skin cell growth. Vitamin D analogs like calcipotriene (Dovonex) 0.005% ointment can be applied twice daily, alone or in combination with steroids.

For scalp involvement, medicated shampoos containing salicylic acid, coal tar, or ketoconazole can help remove scales. Moisturizers should be applied regularly to reduce dryness and itching. The British Association of Dermatologists guidelines for use of biological interventions in psoriasis 2005 1 also support the use of topical therapies as first-line treatments.

When topical treatments are insufficient, primary care physicians may prescribe oral medications such as methotrexate (starting at 7.5-15 mg weekly) or refer to dermatology for biologics. The guidelines for management of patients with psoriasis 1 suggest that systemic treatment may be indicated in cases of failure of adequate trial of topical treatment, repeated hospital admissions for topical treatment, or extensive chronic plaque psoriasis in elderly or infirm people.

Phototherapy, typically narrow-band UVB treatments 2-3 times weekly for 6-8 weeks, may also be prescribed for moderate cases, as recommended by the guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy 1. Patients should be educated about psoriasis triggers, including stress, skin injury, certain medications, and infections, and regular follow-up is essential to monitor treatment efficacy and potential side effects.

Key points to consider in the treatment of plaque psoriasis in primary care include:

• Topical corticosteroids and vitamin D analogs as first-line treatments
• Medicated shampoos for scalp involvement
• Moisturizers to reduce dryness and itching
• Phototherapy for moderate cases
• Oral medications or biologics for insufficient topical treatment
• Patient education on psoriasis triggers and regular follow-up to monitor treatment efficacy and potential side effects.

From the FDA Drug Label

Calcipotriene ointment, 0.005%, is indicated for the treatment of plaque psoriasis in adults. Subjects in all treatment groups and in both studies had a median baseline PASI score ranging from 15 to 17, and the percentage of subjects with baseline sPGA classifications ranged from 54% to 66% for moderate, 17% to 26% for marked and 1% to 5% for severe More subjects randomized to Enbrel than placebo achieved at least a 75% reduction from baseline PASI score (PASI 75) with a dose response relationship across doses of 25 mg once a week, 25 mg twice a week and 50 mg twice a week

The treatment for Plaque Psoriasis in primary care includes:

• Topical calcipotriene (0.005%) for adults 2
• Etanercept (SQ) with a dose response relationship across doses of 25 mg once a week, 25 mg twice a week and 50 mg twice a week 3 Key points:
• Etanercept (SQ) has been shown to achieve at least a 75% reduction from baseline PASI score (PASI 75)
• Calcipotriene ointment is indicated for the treatment of plaque psoriasis in adults
• The choice of treatment should be based on the individual patient's needs and medical history.

From the Research

Treatment Options for Plaque Psoriasis in Primary Care

• Topical corticosteroids, such as clobetasol propionate, are effective and rapid in healing psoriatic lesions, but their long-term use is limited due to the risk of side effects 4
• Vitamin D analogues, such as calcipotriol, are safe for long-term treatment and can be used in combination with topical corticosteroids for improved efficacy 4, 5
• The combination of potent and superpotent corticosteroids with vitamin D analogues provides an improvement of psoriasis within 2 weeks, reaching a maximal improvement after 4 weeks in the majority of patients 6
• Fixed combination calcipotriol plus betamethasone dipropionate is an effective topical treatment for plaque psoriasis, offering better efficacy, safety, and ease of use compared to separate product monotherapies 7

Recommended Treatment Regimens

• Clobetasol propionate ointment for 2 weeks followed by treatment with calcipotriol ointment for 4 weeks is superior to calcipotriol ointment alone in the treatment of plaque psoriasis 4
• Combination of calcitriol ointment and clobetasol propionate cream is a new regimen for the treatment of plaque psoriasis, providing a safe and effective alternative to calcipotriol ointment 5
• Topical calcipotriol plus betamethasone dipropionate is a recommended treatment option for plaque psoriasis, available in various formulations such as ointment, gel, suspension, foam, and cream 7

Additional Considerations

• Biologics, such as inhibitors to tumor necrosis factor α (TNF-α) and interleukin-17 (IL-17), are recommended as an option for first-line treatment of moderate to severe plaque psoriasis due to their efficacy and acceptable safety profiles 8
• Oral treatments, such as methotrexate and apremilast, and light therapy, such as narrowband UV-B phototherapy, are also available for the treatment of plaque psoriasis 8