What are the treatments for psoriasis?

Treatments for Psoriasis

For psoriasis treatment, a stepwise approach based on disease severity is recommended, starting with topical therapies for mild disease and progressing to phototherapy and systemic agents for more severe cases.

Topical Therapies (First-Line for Mild Disease)

Corticosteroids and Vitamin D Combinations

• Combination of vitamin D analogues (calcipotriene) with potent topical corticosteroids is the most effective topical approach 1
• Calcipotriene 0.005% plus betamethasone dipropionate 0.064% shows superior efficacy compared to either agent alone, with 69-74% of patients achieving clear or almost clear status over 52 weeks 1
• Apply once daily for initial treatment (2-8 weeks), then reduce to weekend-only application for maintenance 1

Topical Corticosteroid Guidelines

• Use appropriate potency based on location:
  • Low to mid-potency for face/flexural areas
  • High potency for thick plaques/palmoplantar psoriasis 2
• Safety precautions:
  • Regular clinical review
  • No unsupervised repeat prescriptions
  • No more than 100g of moderately potent preparation monthly
  • Include steroid-free periods annually 1

Other Topical Options

• Coal tar: Safe and effective, start with 0.5-1.0% concentration and increase to maximum 10% 1
• Dithranol (anthralin): Start at 0.1-0.25% concentration and increase as tolerated 1
• Calcineurin inhibitors (tacrolimus, pimecrolimus): Particularly effective for facial and intertriginous psoriasis 1
• Tazarotene: Useful for stable plaque psoriasis, typically combined with corticosteroids 2

Phototherapy (For Moderate Disease)

• Effective for widespread psoriasis affecting trunk and extremities 1
• Options include:
  • UVB phototherapy
  • PUVA (psoralen plus UVA)
• Note: Vitamin D analogues should be applied after phototherapy to avoid inactivation 1

Systemic Therapies (For Moderate to Severe Disease)

Conventional Systemics

• Methotrexate: Effective for both skin and joint involvement 1
• Cyclosporine: Rapid acting for severe cases 1
• Acitretin: Particularly effective for pustular psoriasis 1

Biologics

• For moderate to severe plaque psoriasis, biologics show highest efficacy 1
• Categories:
  • TNF inhibitors (adalimumab, etanercept)
  • IL-17 inhibitors (secukinumab)
  • IL-12/23 inhibitors
  • IL-23 inhibitors
• Adalimumab (Humira/Hulio): FDA-approved for moderate to severe plaque psoriasis, administered as 80mg initial dose, followed by 40mg every other week 3

Small Molecule Inhibitors

• JAK inhibitors: Effective for both skin and joint disease 1
• PDE4 inhibitors: Option for those who cannot use biologics 1

Special Considerations

Scalp Psoriasis

• Use shampoo, gel, solution, or foam formulations for better application 1
• Options include corticosteroid solutions, vitamin D analogues, coal tar shampoos 2

Nail Psoriasis

• Topical options: Corticosteroids, vitamin D analogues, tazarotene 2
• For severe cases, consider biologics 1

Inverse/Genital Psoriasis

• Use lower potency corticosteroids to minimize atrophy risk
• Calcineurin inhibitors are particularly effective and don't cause atrophy 1

Treatment Algorithm

1. Mild disease (limited plaques, <5% BSA): Start with topical therapy

   • First choice: Combination vitamin D analogue + corticosteroid
   • Alternative: Corticosteroid monotherapy with appropriate potency for location

2. Moderate disease (5-10% BSA):

   • Topical therapy plus phototherapy
   • Consider adding low-dose systemic therapy if inadequate response

3. Severe disease (>10% BSA or disabling symptoms):

   • Biologics or systemic therapy
   • Continue topical therapy as adjunct

Common Pitfalls

• Overuse of potent corticosteroids leading to atrophy, especially in sensitive areas
• Inadequate duration of vitamin D analogue treatment (efficacy noted at 8 weeks, not 4 weeks) 1
• Chemical incompatibility between separate vitamin D and corticosteroid preparations (use formulated combinations) 4
• Certain medications can worsen psoriasis: beta-blockers, NSAIDs, lithium, chloroquine 1

Remember that psoriasis is a chronic condition requiring long-term management. Treatment goals should focus on reducing disease severity, improving quality of life, and minimizing adverse effects.