What to prescribe for a patient with systemic plaque psoriasis while waiting to see a specialist?

From the Guidelines

For a patient with systemic plaque psoriasis awaiting specialist consultation, I recommend starting with topical corticosteroids such as betamethasone dipropionate 0.05% ointment or clobetasol propionate 0.05% cream applied twice daily to affected areas for 2-4 weeks. This can be combined with calcipotriene (a vitamin D analog) 0.005% ointment for enhanced efficacy. For more widespread disease, consider narrow-band UVB phototherapy 2-3 times weekly if available. Oral medications like methotrexate starting at 7.5-15mg once weekly (with folic acid 1mg daily) or acitretin 10-25mg daily can be initiated for moderate-to-severe cases, though these require baseline laboratory monitoring including complete blood count, liver and kidney function tests 1.

Key Considerations

• Topical treatments work by reducing inflammation, cell proliferation, and normalizing keratinocyte differentiation.
• While waiting for specialist care, it's essential to address comorbidities like pruritus with antihistamines such as cetirizine 10mg daily and to recommend gentle skin care with fragrance-free moisturizers applied liberally after bathing.
• Patients should be monitored for side effects including skin atrophy with topical steroids and hepatotoxicity with systemic agents.
• These interventions can provide significant symptomatic relief while awaiting definitive management from a dermatologist.

Monitoring and Follow-Up

• Regular follow-up is necessary to assess the response to treatment and to monitor for potential side effects.
• Laboratory tests, including complete blood count, liver function tests, and kidney function tests, should be performed regularly in patients receiving systemic therapy 1.
• Patients should be educated on the potential risks and benefits of their treatment and should be encouraged to report any concerns or side effects promptly.

Additional Therapies

• For patients with severe or refractory disease, consideration may be given to biologic therapies, such as tumor necrosis factor-alpha inhibitors, which have been shown to be effective in reducing symptoms and improving quality of life 1.
• However, these therapies are typically reserved for patients who have failed other treatments and should be used under the guidance of a specialist.

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.

The patient with systemic plaque psoriasis can be prescribed cyclosporine (PO) at an initial dose of 2.5 mg/kg/day, divided into two doses. The dose can be increased by 0.5 mg/kg/day every 2 weeks if significant clinical improvement is not observed, up to a maximum dose of 4 mg/kg/day. It is essential to monitor the patient for adverse events and adjust the dose accordingly 2.

• Key considerations:
  • Initial dose: 2.5 mg/kg/day
  • Dose increase: 0.5 mg/kg/day every 2 weeks
  • Maximum dose: 4 mg/kg/day
  • Monitoring: Adverse events, clinical response 2

From the Research

Systemic Plaque Psoriasis Treatment Options

While waiting to see a specialist, the following treatment options can be considered for a patient with systemic plaque psoriasis:

• Methotrexate (MTX) is a commonly used systemic treatment for moderate to severe plaque psoriasis 3, 4, 5, 6, 7
• The efficacy of MTX can be influenced by factors such as dosage, route of administration, and combination with folic acid 4, 5, 6, 7
• Weekly administration of MTX is generally considered more effective than daily administration 4
• A fixed dose of 25mg MTX once weekly may be more effective than a dose of 10mg once weekly 5
• Subcutaneous administration of MTX may be considered as an alternative to oral administration 6

Dosage and Administration

• The initial dosage of MTX can impact efficacy, with higher doses in the first month associated with superior efficacy 7
• The cumulative dose of MTX after 4 weeks can also impact efficacy, with doses greater than 60mg associated with higher PASI 75 rates 7
• Folic acid can be used in combination with MTX to reduce the risk of adverse events such as hepatic cytolysis and digestive disorders 3, 7

Adverse Events

• MTX can be associated with adverse events such as nausea, abdominal pain, asthenia, and moderate hepatic cytolysis 3, 4, 5, 6, 7
• The frequency of adverse events can be correlated with MTX dosage, with higher doses associated with more frequent adverse events 7
• Regular monitoring of liver function tests and complete blood counts can help to minimize the risk of adverse events 3, 4, 5, 6, 7