What are the treatment options for psoriasis?

Treatment Options for Psoriasis

The treatment of psoriasis should follow a stepwise approach based on disease severity, with topical agents as first-line for mild to moderate disease, and phototherapy or systemic agents for moderate to severe disease. 1

Disease Classification and Initial Assessment

• Mild psoriasis: <5% body surface area (BSA)
• Moderate to severe psoriasis: ≥5% BSA or involvement of vulnerable areas (face, genitals, hands, feet)
• Erythrodermic psoriasis: Widespread inflammation requiring urgent intervention

Important Assessment Factors

• Extent of body surface area involved
• Patient's perception of disability and quality of life impact
• Presence of psoriatic arthritis
• Location of lesions (especially vulnerable areas)
• Previous treatment responses

Treatment Algorithm by Disease Severity

1. Mild Psoriasis (<5% BSA)

First-line options:

• Topical corticosteroids - Start with mid-potency for body, low-potency for face/intertriginous areas
• Topical vitamin D analogs (calcipotriene) - Often used in combination with corticosteroids
• Topical retinoids (tazarotene) - Effective in 1-2 weeks
• Coal tar preparations - Extremely safe but messier, effective in 2-4 weeks

Important corticosteroid guidelines:

• Regular clinical review required
• No unsupervised repeat prescriptions
• No more than 100g of moderately potent preparation monthly
• Include steroid-free periods yearly
• Very potent/potent preparations only under dermatological supervision 1

2. Moderate to Severe Psoriasis (≥5% BSA)

First-line options (alphabetical order):

• Acitretin - Oral retinoid (contraindicated in women of childbearing potential)
• Biologic agents - Adalimumab, infliximab, ustekinumab
• Cyclosporine - For short-term (3-4 month) interventional courses
• Methotrexate - Traditional systemic agent
• Phototherapy - NB-UVB particularly useful in pregnancy 1

Second-line combination options:

• Acitretin + cyclosporine
• Acitretin + TNF blocker
• Cyclosporine + methotrexate
• Methotrexate + TNF blocker 1

3. Erythrodermic Psoriasis (Severe, Unstable)

Initial management for all patients:

• Wet dressings with mid-potency topical steroids
• Attention to fluid balance and ankle edema control
• Rule out sepsis

First-line systemic therapy:

• Cyclosporine (3-5 mg/kg/day) - Preferred due to rapid onset of action
• Alternative options: methotrexate (subcutaneous administration) or TNF inhibitors 1

Special Considerations

Psoriatic Arthritis

When psoriasis is accompanied by joint involvement, prioritize:

• TNF inhibitors (adalimumab, infliximab)
• Methotrexate
• These agents address both skin and joint manifestations 1, 2

Pregnant Patients

• NB-UVB phototherapy is first-line for moderate-severe disease
• Avoid acitretin (teratogenic) and methotrexate (affects spermatogenesis) 1

Intertriginous/Inverse Psoriasis

• Use low-potency corticosteroids for short periods
• Topical immunomodulators (tacrolimus, pimecrolimus) are effective alternatives 3

Biologic Therapy Details

For moderate to severe plaque psoriasis, adalimumab is administered:

• Initial dose: 80 mg
• Maintenance: 40 mg every other week starting one week after initial dose 2

Combination Approaches

Combination therapy often provides superior efficacy with reduced side effects:

• Calcipotriene + betamethasone dipropionate shows rapid and substantial improvement 4
• Methotrexate + phototherapy (UVB) produces synergistic effects 1
• Acitretin + phototherapy increases response rates while decreasing total UV exposure 1
• Topical corticosteroids can be added to biologic therapy for resistant plaques 5

Common Pitfalls to Avoid

1. Overuse of topical corticosteroids - Can lead to skin atrophy, telangiectasia, and tachyphylaxis
2. Inadequate monitoring of systemic therapies - Regular blood work needed for methotrexate and cyclosporine
3. Abrupt discontinuation of systemic corticosteroids - Can trigger severe flares
4. Ignoring drug interactions - Particularly with cyclosporine
5. Failing to screen for TB before starting TNF inhibitors
6. Using acitretin in women of childbearing potential - Teratogenic risk extends for years after discontinuation

Remember that psoriasis is a chronic disease requiring long-term management. For mild-moderate disease, intermittent corticosteroid therapy (weekend-only or every-other-day application) may be effective for maintenance after initial control is achieved 3.