What is the best treatment approach for a patient with suspected psoriasis (Psoriasis) who has tried hydrocortisone (Hydrocortisone) without improvement?

From the Guidelines

For a patient with suspected psoriasis who hasn't responded to hydrocortisone, the best approach would be to escalate to a combination of calcipotriene and a potent topical corticosteroid, such as betamethasone dipropionate, as this combination has been shown to be more effective than either agent alone 1. This approach is supported by the joint AAD-NPF guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures, which found that the combination of calcipotriene and betamethasone dipropionate was more effective than vehicle in achieving an Investigator’s Static Global Assessment score of 0 (clear) or 1 (almost clear) after 8 weeks of treatment 1. Some key points to consider when treating psoriasis include:

• The use of vitamin D analogues, such as calcipotriene, which have been shown to be effective in the treatment of psoriasis, especially when combined with topical corticosteroids 1
• The importance of confirming the diagnosis with a dermatologist if there's uncertainty, as psoriasis requires different management than other skin conditions
• The need to counsel patients on avoiding triggers like stress and skin trauma, using moisturizers regularly, and understanding that psoriasis is a chronic condition requiring ongoing management
• The potential for phototherapy, such as narrowband UVB treatments, or referral to dermatology for systemic options like methotrexate, biologics, or oral retinoids for more extensive disease 1. It's also important to note that the treatment of psoriasis should be individualized and based on the severity of the disease, as well as the patient's medical history and other factors 1.

From the FDA Drug Label

The initial dose of cyclosporine [MODIFIED] should be 2.5 mg/kg/day. Cyclosporine [MODIFIED] should be taken twice daily, as a divided (1.25 mg/kg b.i.d.) oral dose. Patients should be kept at that dose for at least 4 weeks, barring adverse events. If significant clinical improvement has not occurred in patients by that time, the patient's dosage should be increased at 2 week intervals. Based on patient response, dose increases of approximately 0.5 mg/kg/day should be made to a maximum of 4 mg/kg/day. Dose decreases by 25% to 50% should be made at any time to control adverse events, e.g., hypertension, elevations in serum creatinine (≥ 25% above the patient's pretreatment level), or clinically significant laboratory abnormalities. Patients generally show some improvement in the clinical manifestations of psoriasis in 2-weeks. Satisfactory control and stabilization of the disease may take 12 to 16 weeks to achieve Results of a dose-titration clinical trial with cyclosporine [MODIFIED] indicate that an improvement of psoriasis by 75% or more (based on PASI) was achieved in 51% of the patients after 8 weeks and in 79% of the patients after 16 weeks. Treatment should be discontinued if satisfactory response cannot be achieved after 6 weeks at 4 mg/kg/day or the patient's maximum tolerated dose Once a patient is adequately controlled and appears stable the dose of cyclosporine [MODIFIED] should be lowered, and the patient treated with the lowest dose that maintains an adequate response (this should not necessarily be total clearing of the patient) In clinical trials, cyclosporine doses at the lower end of the recommended dosage range were effective in maintaining a satisfactory response in 60% of the patients. Doses below 2.5 mg/kg/day may also be equally effective.

The best treatment approach for a patient with suspected psoriasis who has tried hydrocortisone without improvement is to start with an initial dose of cyclosporine at 2.5 mg/kg/day, taken twice daily. The dose can be increased by 0.5 mg/kg/day every 2 weeks if significant clinical improvement is not seen, up to a maximum of 4 mg/kg/day.

• Key considerations:
  • Monitor serum creatinine and blood pressure regularly
  • Adjust the dose based on patient response and adverse events
  • Discontinue treatment if satisfactory response is not achieved after 6 weeks at the maximum tolerated dose
  • Use the lowest effective dose to maintain an adequate response
  • Consider alternating with other forms of treatment for long-term management 2
• Important safety information:
  • Cyclosporine can cause renal dysfunction and hypertension
  • Monitor laboratory tests, including serum creatinine, BUN, and liver enzymes, regularly
  • Avoid concomitant use of drugs that may potentiate renal dysfunction 2

From the Research

Treatment Approach for Suspected Psoriasis

The patient's symptoms, including multiple skin tags of different sizes with scales all over the body, suggest a diagnosis of psoriasis. Given that the patient has tried hydrocortisone without improvement, the following treatment options can be considered:

• Topical agents, such as vitamin D analogs, keratolytics, and calcipotriol/betamethasone propionate compound, which can be used alone or in combination with corticosteroids 3, 4
• Combination therapy with vitamin D analogs and topical corticosteroids, which can work synergistically to improve efficacy and reduce side effects 4, 5
• Biologics, such as inhibitors of tumor necrosis factor α (TNF-α), interleukin-12 (IL-12), interleukin-17 (IL-17), and interleukin-23 (IL-23), which can be used as first-line treatment for moderate to severe plaque psoriasis 6
• Oral treatments, such as methotrexate, acitretin, cyclosporine, and apremilast, which can be used for moderate to severe psoriasis 6
• Light therapy, such as narrowband UV-B phototherapy, which can be used to treat plaque psoriasis 6

Considerations for Treatment

When selecting a treatment approach, the following factors should be considered:

• Disease severity: mild, moderate, or severe psoriasis 3, 6, 7
• Patient's medical history and comorbidities: psoriatic arthritis, cardiometabolic diseases, and mental health disorders 6, 7
• Patient's preferences and lifestyle: topical treatments, oral medications, or biologics 7
• Potential side effects and interactions: vitamin D analogs, corticosteroids, and biologics 4, 5

Next Steps

Given the patient's symptoms and lack of response to hydrocortisone, a referral to a dermatologist may be necessary to further evaluate and manage the patient's condition 7. Additionally, a thorough review of the patient's medical history and comorbidities should be conducted to determine the best course of treatment 6, 7.