What is the next line of treatment for plaque psoriasis after inadequate response to steroid (corticosteroid) treatment?

Next Line Treatment for Plaque Psoriasis After Inadequate Response to Steroids

After inadequate response to topical corticosteroids, narrowband UVB (NB-UVB) phototherapy should be considered as the next line treatment for plaque psoriasis, followed by PUVA if NB-UVB is ineffective. 1

Treatment Algorithm for Plaque Psoriasis After Steroids

First-Line After Steroids: Phototherapy

1. Narrowband UVB (NB-UVB)

   • First phototherapy option to try
   • Typically administered 3 times per week for at least 3 months 2
   • More effective than broadband UVB and safer than PUVA
   • Particularly useful for widespread plaque psoriasis

2. PUVA (Psoralen plus UVA)

   • Should only be considered if NB-UVB has not been adequately effective 1
   • Options include bath PUVA or oral PUVA
   • Higher risk profile than NB-UVB (increased risk of skin cancer)
   • More effective for thick and extensive plaque psoriasis

Second-Line After Phototherapy: Systemic Agents

If phototherapy fails, the following systemic medications should be considered:

1. Traditional Systemic Agents:

   • Methotrexate - Effective for both skin and joint involvement 1
   • Cyclosporine - Rapid onset of action, but limited to short courses (3-4 months) due to toxicity concerns 1
   • Acitretin - Oral retinoid (contraindicated in women of childbearing potential) 1

2. Biologic Agents:

   • Should be considered after failure of at least one traditional systemic therapy 1
   • TNF inhibitors (adalimumab, etanercept, infliximab) 3
   • IL-17 inhibitors and IL-23 inhibitors

Important Clinical Considerations

Factors Affecting Treatment Selection

• Disease severity and extent - More extensive disease may require systemic therapy sooner
• Psoriasis location - Scalp, palmoplantar, and inverse psoriasis may require specific approaches
• Comorbidities - Presence of psoriatic arthritis favors methotrexate or biologics
• Patient factors - Age, sex, pregnancy potential, and ability to adhere to treatment regimens

Monitoring and Safety

• Phototherapy: Monitor for erythema, burning, and long-term skin cancer risk
• Systemic agents: Regular monitoring of liver function, blood counts, and kidney function
• Biologics: Screening for tuberculosis and other infections prior to initiation 3

Common Pitfalls to Avoid

1. Prolonged use of high-potency topical steroids - Can lead to tachyphylaxis, skin atrophy, and systemic absorption
2. Underutilization of phototherapy - Often overlooked despite strong evidence for efficacy
3. Delayed escalation of therapy - Continuing ineffective treatments too long can lead to unnecessary disease burden
4. Inadequate patient education - Poor adherence often results from insufficient understanding of treatment regimens

Combination Approaches

Combination therapy may provide enhanced efficacy:

• NB-UVB with topical vitamin D analogs
• Acitretin with phototherapy
• Methotrexate with biologics for enhanced efficacy 1

The treatment pathway should prioritize therapies with the best balance of efficacy, safety, and tolerability. While phototherapy remains the recommended next step after topical steroids, systemic agents should be promptly considered when phototherapy is ineffective or impractical.