Treatment Options for Psoriasis
Treatment for psoriasis should be tailored based on disease severity, affected body areas, and presence of psoriatic arthritis, with biologics being the most effective option for moderate-to-severe disease. 1
Disease Classification and Treatment Approach
Psoriasis treatment follows a stepwise approach based on disease severity:
Limited Disease (< 5% Body Surface Area)
- First-line: Topical therapies 1
- Topical corticosteroids (following guidelines to prevent side effects)
- Vitamin D analogues (calcipotriene)
- Topical retinoids (tazarotene)
- Coal tar preparations (0.5-10% concentration)
- Dithranol/anthralin (starting at 0.1-0.25% concentration)
Moderate-to-Severe Disease (≥ 5% BSA or affecting special sites)
Special sites include face, genitals, hands/feet, scalp, or intertriginous areas that significantly impact quality of life 1
Treatment Algorithm:
Phototherapy 1
- UVB therapy
- PUVA (psoralen + UVA) - considered least toxic of systemic options
- Caution: Commercial sunbeds are not recommended 1
Conventional Systemic Agents 1
- Methotrexate
- Cyclosporine (limit to <12 months due to cumulative toxicity)
- Acitretin
- Fumaric acid esters
Biologics and Small Molecules 1, 2, 3
- TNF inhibitors: Adalimumab, etanercept, infliximab, certolizumab
- IL-17 inhibitors: Secukinumab, ixekizumab, brodalumab, bimekizumab
- IL-12/23 inhibitor: Ustekinumab
- IL-23 inhibitors: Guselkumab, risankizumab, tildrakizumab
- Small molecules: Apremilast, JAK inhibitors
Special Clinical Scenarios
Psoriatic Arthritis
When psoriasis is accompanied by psoriatic arthritis, treatment should address both skin and joint manifestations 1:
- Mild peripheral arthritis: NSAIDs, intra-articular glucocorticoid injections
- Moderate-to-severe peripheral arthritis: DMARDs (methotrexate, sulfasalazine, leflunomide) or TNF inhibitors
- Axial disease: NSAIDs, physiotherapy, TNF inhibitors
- Enthesitis: NSAIDs, physical therapy, TNF inhibitors for severe cases
- Dactylitis: NSAIDs, corticosteroids, DMARDs, infliximab for resistant cases
Special Forms of Psoriasis
- Erythrodermic/Generalized pustular psoriasis: Hospital admission and systemic agents; acitretin as first-line 1
- Palmoplantar pustulosis: Acitretin and oral PUVA (combination provides superior response) 1
- Hand/foot psoriasis: Topical PUVA, acitretin 1
Effectiveness of Treatments
According to high-quality evidence from network meta-analysis, the most effective treatments for achieving PASI 90 (90% improvement) are 3:
- Infliximab
- Bimekizumab
- Ixekizumab
- Risankizumab
These biologics demonstrated significantly higher efficacy compared to conventional systemic agents 3.
Important Considerations and Precautions
- Pregnancy: All commonly used systemic agents are contraindicated in pregnancy 1
- Monitoring: Regular clinical review is essential for all treatments, especially systemic therapies 1
- Rotation therapy: Consider rotating treatments every 1-2 years to minimize cumulative toxicity 4
- Comorbidities: Assess for psoriatic arthritis, cardiovascular disease, metabolic syndrome, and psychological impacts 5
- Tapering: When disease control is achieved, tapering therapy may be considered with patient involvement in the decision 1
Pitfalls to Avoid
- Systemic corticosteroids: Generally avoided in psoriasis as skin disease can flare during or after taper 1
- Overuse of topical corticosteroids: Follow guidelines to prevent skin atrophy and tachyphylaxis 1
- Phototherapy risks: Long-term use increases risk of skin cancer, especially after PUVA 1
- Biologics after phototherapy: Avoid aggressive immunosuppression following extensive phototherapy due to increased skin cancer risk 1
- Undertreatment: Failing to escalate therapy when response is inadequate can lead to unnecessary disease burden 1
By following this evidence-based approach to psoriasis treatment, clinicians can effectively manage this chronic condition and improve patients' quality of life.