What are the recommended treatment options for psoriasis?

Recommended Treatment Options for Psoriasis

The recommended first-line treatment for psoriasis depends on disease severity, with topical corticosteroids combined with vitamin D analogs being the cornerstone therapy for mild to moderate disease, while biologics such as TNF-α inhibitors are recommended for moderate to severe psoriasis that fails to respond to topical therapy.

Disease Severity Assessment

Disease severity determines the appropriate treatment approach:

• Mild psoriasis (criteria for topical therapy alone):

  • Less than 5% body surface area (BSA) affected
  • Generally asymptomatic
  • Minimal impact on quality of life
  • Responsive to localized therapy 1

• Moderate to severe psoriasis (candidates for systemic/phototherapy):

  • Greater than 5% BSA affected OR
  • Symptomatic (pain, bleeding, itching)
  • Significant impact on quality of life
  • Inadequate response to topical therapy
  • Special locations (face, genitals, hands/feet, nails, scalp, intertriginous areas)
  • Guttate, erythrodermic, or pustular psoriasis 1

Treatment Algorithm Based on Severity

Mild Psoriasis (First-Line)

1. Topical corticosteroids:

   • Class 1 (ultrahigh-potency) for thick, chronic plaques
   • Class 2-5 (high to moderate potency) for most other presentations
   • Class 6-7 (low potency) for face and intertriginous areas 2
   • Initial treatment limited to 2-4 weeks 2

2. Vitamin D analogs:

   • Long-term use (up to 52 weeks) is recommended for mild to moderate psoriasis
   • Examples: calcipotriene, calcitriol, tacalcitol 1

3. Combination therapy:

   • Vitamin D analogs + corticosteroids are more effective than either agent alone
   • Can be used as separate products or combination products
   • Apply vitamin D in morning and corticosteroid in evening, OR
   • Use corticosteroids on weekends and vitamin D on weekdays 1, 2

4. Adjunctive treatments:

   • Emollients to reduce itching, desquamation, and prevent relapse when corticosteroids are discontinued 1
   • Salicylic acid for thick plaques (but avoid combining with calcipotriene) 1

Moderate to Severe Psoriasis

1. Phototherapy:

   • UVB or PUVA for patients with >5% BSA affected
   • Apply vitamin D analogs after phototherapy to avoid inactivation 1

2. Traditional systemic agents:

   • Methotrexate
   • Acitretin (first-line for erythrodermic/generalized pustular psoriasis)
   • Cyclosporine 1

3. Biologic agents (for inadequate response to traditional therapy):

   • TNF-α inhibitors:

     • Etanercept: 50mg twice weekly for 12 weeks, then 50mg weekly for maintenance 1
     • Infliximab: 5mg/kg at weeks 0,2, and 6, then every 8 weeks 1
     • Adalimumab: 80mg initial dose, followed by 40mg every other week 3

   • IL-12/23 inhibitors (e.g., ustekinumab) 1

Special Considerations for Specific Locations

1. Scalp psoriasis:

   • Calcipotriene foam and calcipotriene plus betamethasone dipropionate gel (4-12 weeks) 1
   • Solutions, foams, and sprays are ideal for scalp application 2

2. Nail psoriasis:

   • Topical vitamin D analogs combined with betamethasone dipropionate 1
   • Infliximab for more severe cases 1

3. Facial psoriasis:

   • Topical tacalcitol ointment or calcipotriene combined with hydrocortisone (8 weeks) 1
   • Tacrolimus and pimecrolimus for facial and intertriginous areas 4

4. Palmoplantar psoriasis:

   • Topical maxcalcitol ointment as initial treatment 1
   • High-potency corticosteroids 4

Treatment Pitfalls and Caveats

1. Corticosteroid-related issues:

   • Prolonged use can cause skin atrophy, striae, folliculitis, telangiectasia
   • Abrupt discontinuation can lead to rebound phenomenon 2
   • Extended use beyond 12 weeks should only be done under careful supervision 2

2. Drug interactions:

   • Avoid simultaneous use of salicylic acid with calcipotriene (acid pH inactivates calcipotriene) 1
   • UVA radiation can decrease concentration of calcipotriene on skin 1

3. Systemic therapy considerations:

   • Monotherapy with systemic corticosteroids should be avoided as skin disease can flare during or after taper 1
   • TNF inhibitors require TB screening prior to initiation 3

4. Maintenance strategies:

   • After initial clearance, consider weekend-only steroid use
   • Combination with steroid-sparing agents
   • Switching to lower potency steroids for long-term management 2

By following this evidence-based approach to psoriasis treatment, clinicians can effectively manage the disease while minimizing adverse effects and improving patients' quality of life.