From the Guidelines
Psoriasis treatment should prioritize topical therapies for mild to moderate cases, and systemic medications, including biologics, for severe or resistant cases, considering comorbidities and lifestyle modifications to improve treatment response and quality of life 1.
Psoriasis Presentation
Psoriasis is a chronic autoimmune skin condition characterized by red, scaly patches typically found on the elbows, knees, scalp, and trunk. The presentation can vary from mild to severe, with some cases involving systemic symptoms such as chills and night sweats.
Treatment Options
Treatment depends on the severity of the condition and includes:
- Topical therapies: topical corticosteroids like betamethasone or clobetasol, vitamin D analogs such as calcipotriene, and medicated shampoos containing salicylic acid or coal tar for scalp involvement.
- Phototherapy: UVB or PUVA administered 2-3 times weekly for 2-3 months for moderate to severe cases.
- Systemic medications: methotrexate, cyclosporine, biologics like adalimumab, etanercept, or ustekinumab, and newer oral medications like apremilast and JAK inhibitors for severe or resistant cases.
Considerations for Treatment Selection
Treatment selection should consider:
- Comorbidities: psoriatic arthritis, cardiovascular disease, and metabolic syndrome.
- Lifestyle modifications: weight loss, smoking cessation, and stress reduction to manage symptoms and improve treatment response.
- Potential drug interactions and side effects, particularly with systemic medications like cyclosporine and methotrexate 1.
Recommendation
For severe or resistant cases, biologic therapies like adalimumab (40mg every other week) or ustekinumab (45-90mg initially, at 4 weeks, then every 12 weeks) are recommended due to their efficacy and relatively favorable safety profile compared to traditional systemic agents 1.
From the FDA Drug Label
Plaque Psoriasis (Ps) (1. 7): treatment of adult patients with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy, and when other systemic therapies are medically less appropriate. HUMIRA is a tumor necrosis factor (TNF) blocker indicated for: ... Psoriatic Arthritis (PsA) (1.3): reducing signs and symptoms, inhibiting the progression of structural damage, and improving physical function in adult patients with active PsA. Plaque Psoriasis or Adult Uveitis (2.5): Adults: 80 mg initial dose, followed by 40 mg every other week starting one week after initial dose.
Psoriasis Presentation and Treatment:
- Psoriasis is a condition that can be treated with adalimumab (HUMIRA) in adult patients with moderate to severe chronic plaque psoriasis.
- Treatment involves an initial dose of 80 mg, followed by 40 mg every other week starting one week after the initial dose 2.
- Indications include reducing signs and symptoms, inhibiting the progression of structural damage, and improving physical function in adult patients with active psoriatic arthritis (PsA) 2 and treating adult patients with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy 2.
From the Research
Psoriasis Presentation
- Psoriasis is a systemic inflammatory disease associated with increased risk of comorbidities, such as psoriatic arthritis, Crohn's disease, malignancy, obesity, and cardiovascular diseases 3
- The disease can have a significant impact on the quality of life of patients, and treatment regimens should be tailored to meet the specific needs based on disease severity and the presence of comorbidities 3
Treatment Options
- Topical treatments combining corticosteroids and vitamin D analogues are well-established first-line treatments in mild-to-moderate psoriasis 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 5
- Biologics have greatly improved psoriasis management, and can be used in combination with conventional systemic agents or phototherapy to optimize outcomes 6
- The choice of biologic agent should be based on disease severity, comorbid conditions, and patient-related factors, such as psoriatic arthritis, multiple sclerosis, congestive heart failure, inflammatory bowel disease, hepatitis B, and latent tuberculosis 7
Treatment Considerations
- Patient lifestyle and preferences should be taken into account when selecting a treatment regimen 4
- The presence of comorbidities, such as psoriatic arthritis, Crohn's disease, malignancy, obesity, and cardiovascular diseases, can impact the choice of treatment 3
- Treatment regimens should be tailored to meet the specific needs of each patient, based on disease severity, the impact on quality of life, and the response to previous therapies 3
Combination Therapy
- Combination therapy with biologics and conventional systemic agents or phototherapy can be an effective treatment option for patients with psoriasis 6
- The combination of biologics with methotrexate, acitretin, or cyclosporin can provide improved treatment outcomes and longer survival rates on treatment 6
- However, wide geographical variations in treatment selection and persistence of combination treatment exist, and further studies are needed to determine the optimal combination therapy regimens 6