What are the treatment guidelines for psoriasis?

From the Guidelines

Treatment for psoriasis should follow a stepwise approach based on disease severity, starting with topical therapies for mild cases and progressing to systemic treatments, including biologics, for more extensive or severe disease, as recommended by the most recent guidelines 1. The treatment approach for psoriasis typically involves a combination of topical therapies, phototherapy, and systemic treatments. For mild psoriasis affecting less than 3% of body surface area, topical therapies are the first line, including:

• Corticosteroids (such as betamethasone or clobetasol)
• Vitamin D analogs (calcipotriene)
• Combinations like Enstilar foam (calcipotriene/betamethasone) These should be applied once or twice daily to affected areas for 2-4 weeks, with maintenance therapy as needed.

For moderate to severe psoriasis, phototherapy with narrowband UVB (3 sessions weekly for 2-3 months) may be used. When these approaches fail or for more extensive disease, systemic treatments are recommended, including:

• Methotrexate (starting at 7.5-15mg weekly)
• Cyclosporine (2.5-5mg/kg/day)
• Biologics like TNF inhibitors (adalimumab, etanercept), IL-17 inhibitors (secukinumab, ixekizumab), IL-23 inhibitors (guselkumab, risankizumab), or IL-12/23 inhibitors (ustekinumab) These treatments target the underlying immune dysfunction in psoriasis, particularly the overactivation of T-cells and inflammatory cytokines that lead to the rapid skin cell turnover characteristic of the disease.

Some key points to consider when treating psoriasis include:

• Patient education and counseling are essential to optimize treatment outcomes 1
• Lifestyle factors, such as maintaining a healthy weight, avoiding alcohol, quitting smoking, and managing stress, can trigger flares and should be addressed
• Regular monitoring for side effects is essential, especially with systemic medications that may affect liver function or immune response
• The selection of one drug over another should be influenced by the results of head-to-head studies in psoriasis populations, the presence of comorbidities, and disease activity in other psoriatic arthritis domains 1

From the FDA Drug Label

HUMIRA is a tumor necrosis factor (TNF) blocker indicated for: ... 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. The treatment guidelines for psoriasis include the use of adalimumab (SQ) for 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 2.

• Key points:
  • Adult patients with moderate to severe chronic plaque psoriasis
  • Candidates for systemic therapy or phototherapy
  • When other systemic therapies are medically less appropriate Note that clobetasol (TOP) is a topical corticosteroid, and while it may be used to treat psoriasis, the label does not provide specific treatment guidelines for psoriasis 3.

From the Research

Treatment Guidelines for Psoriasis

The treatment guidelines for psoriasis vary depending on the severity of the disease and the presence of comorbidities.

• For mild psoriasis, topical treatments such as corticosteroids, calcipotriene, tazarotene, topical tars, anthralin, and keratolytics are recommended 4, 5.
• For moderate to severe psoriasis, systemic therapies such as methotrexate, acitretin, cyclosporine, hydroxyurea, and biologics may be necessary 4, 6, 7.
• The goals of psoriasis treatment are to gain initial and rapid control of the disease, decrease plaque lesions and percentage of body surface area involved, achieve long-term remission, and minimize adverse events 4.
• Topical corticosteroids are effective as monotherapy or in combination for sequential or rotational treatment, and are often used in combination with other topical agents such as calcipotriene and tazarotene 4, 8.
• The treatment of psoriasis should be tailored to meet the specific needs of each patient, taking into account disease severity, impact on quality of life, response to previous therapies, and presence of comorbidities 6.

Topical Treatments

• Topical corticosteroids are available in a variety of formulations, with a potential ranging from superpotent to least potent (class 1-7) 4.
• Vitamin D3 analogs, such as calcipotriene, are effective in combination with topical corticosteroids, but chemical incompatibility prevents combined application 8.
• A stable formulation of calcipotriene and betamethasone dipropionate has been developed, which has been shown to be effective in reducing Psoriasis Area and Severity Index (PASI) scores 8.
• Other topical treatments, such as retinoids, tars, anthralin, and keratolytics, may be used alone or in combination with topical corticosteroids 4, 5.

Systemic Treatments

• Systemic therapies, such as methotrexate, acitretin, cyclosporine, and hydroxyurea, may be necessary for moderate to severe psoriasis 4, 6, 7.
• Biologics, such as etanercept, infliximab, adalimumab, and ustekinumab, have been shown to be effective in treating psoriasis, but may have potential side effects 6, 7.
• Acitretin is a valuable tool in the treatment of psoriasis, particularly in combination with other systemic treatments or in sequential therapy 7.