What are the treatment options for psoriasis?

Treatment Options 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 moderate-to-severe disease. 1

Treatment Based on Disease Severity

Mild Psoriasis (<5% Body Surface Area)

• First-line therapy:

  • Combination of topical corticosteroids and vitamin D analogs 1
  • Potency selection based on location:
    • Low potency (Class 6-7): Face, intertriginous areas, genitals
    • Medium to high potency (Class 2-5): Trunk, extremities
    • Ultra-high potency (Class 1): Thick plaques, palms/soles 1

• Alternative topical options:

  • Coal tar preparations
  • Salicylic acid (for thick plaques)
  • Anthralin/dithranol
  • Tazarotene (retinoid) 2
  • Calcineurin inhibitors (tacrolimus, pimecrolimus) for facial/intertriginous areas 2

Moderate Psoriasis (5-10% Body Surface Area)

• First-line therapy:

  • Phototherapy (narrowband UVB) 1
  • Can be combined with topical agents

• Second-line options:

  • Conventional systemic agents:
    • Methotrexate (most widely used, cost-effective) 1
    • Acitretin (particularly effective for pustular forms) 1
    • Cyclosporine (short courses of 3-4 months) 1

Severe Psoriasis (>10% Body Surface Area)

• First-line therapy:

  • Biologic agents 3:
    • TNF inhibitors (adalimumab, etanercept, infliximab)
    • IL-17 inhibitors (secukinumab, ixekizumab, brodalumab)
    • IL-12/23 inhibitor (ustekinumab)
    • IL-23 inhibitors (guselkumab, tildrakizumab, risankizumab)

• Alternative systemic options:

  • Methotrexate (7.5-25 mg weekly)
  • Cyclosporine (3-5 mg/kg/day)
  • Apremilast (PDE4 inhibitor) 3

Special Considerations for Specific Types

Scalp Psoriasis

• Medicated shampoos containing coal tar, salicylic acid
• Solutions, foams of corticosteroids or vitamin D analogs
• Clobetasol propionate shampoo for moderate-severe cases 2

Nail Psoriasis

• Topical vitamin D analogs with betamethasone dipropionate
• Intralesional corticosteroids
• Systemic therapy for severe cases (infliximab shows good efficacy) 1, 4

Psoriatic Arthritis

• NSAIDs for mild disease
• DMARDs (sulfasalazine, leflunomide, methotrexate) for moderate disease
• TNF inhibitors for moderate-severe disease 4
• Early treatment is crucial to prevent joint damage

Pustular/Erythrodermic Psoriasis

• Hospitalization may be required
• Cyclosporine (3-5 mg/kg/day) for rapid response
• Acitretin is particularly effective for pustular forms 1, 4

Phototherapy Options

• Narrowband UVB (NB-UVB):

  • First-line for moderate-severe psoriasis
  • Safe during pregnancy
  • Treatment 2-3 times weekly for 20-30 sessions 1

• PUVA (Psoralen + UVA):

  • More effective than NB-UVB but higher skin cancer risk
  • Requires eye protection and avoidance of sun exposure on treatment days 4

Biologic Therapy Details

For moderate-severe psoriasis, adalimumab (Humira) dosing:

• Initial dose: 80 mg subcutaneously
• Maintenance: 40 mg every other week starting one week after initial dose 5

Treatment Monitoring and Adverse Effects

• Assess treatment response after 4 weeks for topical therapy
• Monitor for skin atrophy, telangiectasia with corticosteroid use
• For systemic agents:
  • Methotrexate: Regular liver function tests
  • Cyclosporine: Blood pressure, renal function
  • Biologics: Screen for tuberculosis before initiation 1

Common Pitfalls to Avoid

1. Prolonged use of high-potency corticosteroids leading to skin atrophy
2. Inadequate duration of treatment resulting in delayed clinical improvement
3. Poor adherence due to complex regimens
4. Failure to rotate treatments leading to tachyphylaxis
5. Using commercial sunbeds instead of medical phototherapy 4
6. Not considering comorbidities when selecting treatment (e.g., psoriatic arthritis)

Maintenance Therapy

• Weekend-only corticosteroid application
• Combination with steroid-sparing agents
• Switching to lower potency steroids for long-term management 1
• Regular follow-up to assess disease control and medication side effects

Remember that psoriasis is a chronic disease requiring long-term therapy, making treatments with favorable long-term safety and efficacy profiles crucial 6.