What are the treatment options for psoriasis?

Treatment Options for Psoriasis

Topical treatments are the cornerstone of therapy for mild to moderate psoriasis, while systemic and biologic agents are recommended for moderate to severe disease that fails to respond to topical therapy. 1, 2

Classification of Psoriasis Severity

Disease severity determines the appropriate treatment approach:

• Mild psoriasis: Generally asymptomatic, minimal impact on quality of life, less than 5% body surface area (BSA) affected
• Moderate to severe psoriasis: Symptomatic (pain, bleeding, itching), significant impact on quality of life, BSA greater than 5%, or psoriasis in vulnerable areas (face, genitals, hands/feet, nails, scalp, intertriginous areas) 1

First-Line Treatment for Mild to Moderate Psoriasis

Topical Corticosteroids

• Potency selection: Choose based on disease severity, location, and patient factors
  • Class 1 (ultrahigh-potency): For thick, chronic plaques (e.g., clobetasol propionate 0.05%, halobetasol propionate 0.05%)
  • Class 2-5 (high to moderate potency): For most initial therapy (e.g., betamethasone dipropionate 0.05%, triamcinolone acetonide 0.1%)
  • Lower potency: For face, intertriginous areas, and areas susceptible to steroid atrophy 1, 2

Vitamin D Analogues

• Long-term use (up to 52 weeks) of calcipotriene, calcitriol, tacalcitol is recommended for mild to moderate psoriasis 1
• Avoid combining with salicylic acid as the acidic pH inactivates calcipotriene 1

Combination Therapy

• Vitamin D analogues + topical corticosteroids: Recommended for up to 52 weeks 1
  • Morning application of corticosteroid and evening application of vitamin D analogue is effective 1
  • Weekend-only corticosteroid with weekday vitamin D analogue application is effective for maintenance 1

Special Locations

• Scalp psoriasis: Calcipotriene foam and calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 1, 2
• Facial psoriasis: Tacalcitol ointment or calcipotriene combined with hydrocortisone for 8 weeks 1, 2
• Nail psoriasis: Topical vitamin D analogues combined with betamethasone dipropionate 1, 2
• Palmoplantar psoriasis: Topical maxacalcitol ointment as initial treatment 1, 2

Treatment for Moderate to Severe Psoriasis

Phototherapy

• Narrow-band UVB is recommended for moderate psoriasis 1
• Particularly useful for pregnant women with moderate to severe disease 1
• Combination with systemic agents: Methotrexate with UVB produces synergistic effects 1

Traditional Systemic Agents

1. Methotrexate: First-line systemic therapy 1
2. Acitretin: Particularly effective for erythrodermic and pustular psoriasis; avoid in women of childbearing potential 1
3. Cyclosporine: Effective for short-term (3-4 month) interventional courses 1

Biologic Agents

• TNF-α inhibitors (adalimumab, infliximab, etanercept): Recommended for moderate to severe psoriasis that fails to respond to topical or traditional systemic therapy 1, 3
• Adalimumab dosing: 80 mg initial dose, followed by 40 mg every other week starting one week after initial dose 3
• Warning: Biologics carry risks of serious infections and malignancy 3

Combination Approaches

Topical + Systemic/Biologic Therapy

• Adding clobetasol propionate spray 0.05% to stable biologic treatment can significantly improve outcomes in patients with moderate to very severe psoriasis 4
• Topical agents can be used as adjunctive therapy with systemic treatments to enhance efficacy and achieve the target of ≤1% BSA involvement 5

Important Considerations and Pitfalls

Steroid-Related Pitfalls

• Avoid prolonged use of high-potency steroids on face, intertriginous areas, and forearms to prevent skin atrophy, striae, folliculitis, telangiectasia, and purpura 2
• Avoid abrupt discontinuation of topical corticosteroids to prevent rebound phenomenon 2
• Avoid systemic corticosteroid monotherapy in psoriasis as skin disease can flare during or after taper 1

Drug Interactions

• Do not use salicylic acid with calcipotriene as it inactivates the vitamin D analogue 1
• Apply vitamin D analogues after phototherapy to avoid inactivation by UVA and blocking of UVB radiation 1

Maintenance Strategies

• Weekend-only steroid use with vitamin D analogues on weekdays 1
• Combination with steroid-sparing agents 2
• Switching to lower potency steroids for long-term management 2
• Coal tar or salicylic acid shampoos 1-2 times weekly for scalp psoriasis maintenance 2

By following this treatment algorithm and considering the specific characteristics of each patient's psoriasis, clinicians can effectively manage this chronic inflammatory condition and improve patients' quality of life.