What is the best treatment approach for a patient experiencing a severe psoriasis flare?

From the Guidelines

For a severe psoriasis flare, the best treatment approach typically involves systemic therapy, and I recommend starting with oral cyclosporine (3-5 mg/kg/day) due to its rapid onset of action, as suggested by the guidelines of care for the management of psoriasis and psoriatic arthritis 1. The treatment of severe psoriasis flares requires a distinct approach, considering the patient's comorbidities, previous treatment responses, and psoriasis subtype.

• Systemic therapy is often necessary for severe psoriasis flares, with options including oral cyclosporine, methotrexate, acitretin, and biologic agents such as TNF inhibitors, IL-17 inhibitors, or IL-23 inhibitors.
• Oral cyclosporine is a logical choice for severe psoriasis flares due to its rapid onset of action, with a recommended dose of 3-5 mg/kg/day 1.
• Biologic agents, such as adalimumab and etanercept, are also effective for severe psoriasis, with recommendations for their use based on disease severity and patient characteristics 1.
• Phototherapy with narrowband UVB can be an effective adjunctive treatment for severe psoriasis, with a recommended treatment frequency of three times weekly 1. The selection of treatment should prioritize the patient's quality of life, considering the potential benefits and risks of each option, as well as the patient's individual characteristics and medical history.
• The treatment approach may involve a combination of systemic therapy, topical treatments, and phototherapy, with regular monitoring to assess the patient's response and adjust the treatment plan as needed.
• It is essential to consider the potential side effects and interactions of each treatment option, particularly when using systemic therapy or biologic agents, to minimize risks and optimize outcomes.

From the FDA Drug Label

HULIO is used: • To treat moderate to severe chronic (lasting a long time) plaque psoriasis (Ps) in adults who have the condition in many areas of their body and who may benefit from taking injections or pills (systemic therapy) or phototherapy (treatment using ultraviolet light alone or with pills). The best treatment approach for a patient experiencing a severe psoriasis flare is to use adalimumab (HULIO), a tumor necrosis factor (TNF) blocker, as it is indicated for the treatment of moderate to severe chronic plaque psoriasis in adults.

• The patient should be a candidate for systemic therapy or phototherapy, and other systemic therapies should be medically less appropriate.
• It is essential to follow the recommended dosage and administration instructions for HULIO, as prescribed by a healthcare provider 2.

From the Research

Treatment Approaches for Severe Psoriasis Flare

• Systemic treatment with conventional and biological preparations is indicated for severe forms of psoriasis 3
• Conventional preparations include methotrexate, cyclosporin, acitretin, and narrow-band ultraviolet B phototherapy, but toxicity may limit the dose and duration of treatment 3
• Biological preparations, such as inhibitors of TNF-alpha (etanercept, adalimumab, infliximab) and the monoclonal antibody against IL 12/23 ustekinumab, are currently used and are less toxic 3

Comparison of Treatment Options

• A study found that infliximab + methotrexate was more effective than acitretin in reducing PASI score at week 12 3
• At week 24, etanercept or adalimumab was more effective than methotrexate in reducing PASI score 3
• No statistically significant differences were found between patient groups in terms of BSA index reduction by 50% or more during the follow-up period 3

Topical Treatment Options

• Topical corticosteroids are effective in reducing symptoms of psoriasis, but may have limitations due to potential side effects 4, 5
• Other topical treatment options include calcipotriene, tazarotene, topical tars, anthralin, and keratolytics, which can be used alone or in combination with corticosteroids 4, 5
• Topical immunomodulators, such as pimecrolimus and tacrolimus, can be effective in treating psoriatic lesions on the face and intertriginous areas 4

Phototherapy

• Ultraviolet B phototherapy is an effective treatment option for patients with >10% affected body surface area who have not responded to topical treatments 6
• Narrowband UVB and targeted phototherapy can be used two to three times weekly until clearance, followed by maintenance treatment before discontinuation 6
• Phototherapy can be used in combination with adjunctive topical treatments, such as emollients, calcipotriene, and corticosteroids 6

Guidelines for Treatment

• Guidelines for the use of acitretin in psoriasis have been established, which provide a detailed account of its pharmacological properties, indications and contraindications, adverse effects, and factors to enhance safe use 7
• Acitretin can be used in monotherapy or in combination with other systemic treatments, and has an important role in the treatment of psoriasis due to its lack of direct immunosuppressive effect and ability to achieve long-term response 7