What are the treatment options for psoriasis?

Psoriasis Treatment Options

Topical corticosteroids combined with vitamin D analogs are the first-line treatment for mild to moderate psoriasis, while phototherapy, methotrexate, or biologics are recommended for moderate to severe disease. 1

Treatment Algorithm Based on Disease Severity

Mild Psoriasis (<3% Body Surface Area)

• First-line therapy: Combination of topical corticosteroid + vitamin D analog (calcipotriene/calcipotriol) 1
  • Start with moderate potency (Class III) corticosteroids for most body areas
  • Use low potency (Class VI-VII) for face, genitals, and intertriginous areas
  • Consider tacrolimus 0.1% ointment for face and genital regions 1
• If inadequate response after 4 weeks:
  • Consider adding tazarotene or switching to higher potency corticosteroid 1
  • Coal tar preparations (0.5-1.0% concentration, can increase to 10%) 2, 1

Moderate Psoriasis (3-10% Body Surface Area)

• First-line therapy: Potent topical therapies as above
• If inadequate response after 4-8 weeks:
  • Phototherapy (narrowband UVB 2-3 times weekly for 20-30 sessions) 1
  • Consider adding topical calcipotriene to methotrexate (7.5-25 mg weekly) 2, 1

Severe Psoriasis (>10% Body Surface Area)

• First-line options:
  • Phototherapy (narrowband UVB or PUVA) 1
  • Methotrexate (7.5-25 mg weekly) 1
  • Biologics (adalimumab, infliximab, ustekinumab) 1, 3
  • Cyclosporine (3-5 mg/kg/day for short courses of 3-4 months) 1
• For enhanced efficacy: Consider combination therapies 1
  • Class 1 topical corticosteroid + etanercept 2
  • Calcipotriene/betamethasone + adalimumab 2

Special Formulations for Specific Areas

Scalp Psoriasis

• Medicated shampoos containing coal tar, salicylic acid
• Solutions or foams of corticosteroids or vitamin D analogs 1

Inverse Psoriasis (Intertriginous Areas)

• Low potency corticosteroids
• Topical calcineurin inhibitors (tacrolimus, pimecrolimus) 1, 4

Nail Psoriasis

• Potent topical corticosteroids
• Intralesional corticosteroids
• Consider systemic therapy if severe 1

Alternative Medicine Options

• Traditional Chinese medicine including herbal methods (only if ingredients are known and well understood)
• Acupuncture (responses relatively minor) 2

Important Considerations and Precautions

• Corticosteroid safety: Use the lowest effective potency, particularly in sensitive areas and in children 1, 5

  • Risk of skin atrophy, telangiectasia, and striae with prolonged use
  • Consider weekend-only or every-other-day application for maintenance 4

• Vitamin D analogs: Maximum 100g per week to avoid hypercalcemia 1

• Biologic therapy precautions: Screen for tuberculosis before initiating therapy 1, 3

  • Monitor for serious infections during treatment
  • Discontinue if serious infection develops 3

• Medication interactions: Certain medications can worsen psoriasis, including alcohol, beta-blockers, NSAIDs, lithium, and antimalarials 1

• Treatment adherence: Patient education on proper application techniques is essential 1

• Regular monitoring: Assess treatment response after 4 weeks and monitor for adverse effects 1

Psoriasis is a chronic condition requiring long-term management. The treatment approach should be adjusted based on disease severity, affected areas, and response to therapy. Combination therapies often provide enhanced efficacy while minimizing side effects of individual agents 2, 1, 6.