What are the treatment options for psoriasis?

Psoriasis Treatment Options

The first-line treatment for mild to moderate psoriasis is a combination of topical corticosteroids and vitamin D analogs, while moderate to severe psoriasis should be treated with biologics targeting TNF-α, IL-17, or IL-23 pathways. 1

Treatment Algorithm Based on Disease Severity

Mild to Moderate Psoriasis

1. Topical Therapies

   • First-line: Combination of topical corticosteroid and vitamin D analog 1
   • Corticosteroid potency selection based on location:
     • Low potency (Class 6-7): Face and intertriginous areas (e.g., hydrocortisone, desonide)
     • Medium to high potency (Class 2-5): Body (e.g., betamethasone dipropionate, triamcinolone acetonide)
     • Ultra-high potency (Class 1): Thick plaques (e.g., clobetasol propionate, halobetasol propionate) 1
   • Apply using fingertip unit method for appropriate coverage
   • Important caution: Use lowest effective potency to minimize risk of skin atrophy, telangiectasia, and striae 1

2. Alternative Topical Options (if inadequate response after 4 weeks)

   • Coal tar preparations (0.5-1.0% concentration, can increase to 10%) 1
   • For scalp psoriasis: Medicated shampoos with coal tar, salicylic acid, or solutions/foams of corticosteroids or vitamin D analogs 1

3. Phototherapy

   • Narrowband UVB: 2-3 times weekly for 20-30 sessions 1
   • PUVA (psoralen + UVA) as alternative (higher skin cancer risk; requires eye protection) 1

Moderate to Severe Psoriasis

1. Biologics (first-line option per American Academy of Dermatology-National Psoriasis Foundation guidelines) 1, 2

   • TNF-α inhibitors: Adalimumab, etanercept, infliximab, certolizumab 3, 2
   • IL-17 inhibitors: Secukinumab, ixekizumab, brodalumab 2
   • IL-12/23 inhibitors: Ustekinumab 2
   • IL-23 inhibitors: Guselkumab, tildrakizumab, risankizumab 2

   Adalimumab dosing for plaque psoriasis: 80 mg initial dose, followed by 40 mg every other week starting one week after initial dose 3

2. Traditional Systemic Agents

   • Methotrexate: 7.5-25 mg weekly (most widely used systemic agent) 1
   • Cyclosporine: 3-5 mg/kg/day for short courses (3-4 months); particularly effective for erythrodermic psoriasis 1
   • Acitretin: Particularly effective for pustular forms; contraindicated during pregnancy/breastfeeding 1

3. Small Molecule Inhibitors

   • Apremilast (PDE4 inhibitor): Can be used in patients with malignancy 1, 2

Special Considerations

Combination Therapies

• Consider combinations for enhanced efficacy and synergistic effects:
  • Methotrexate plus biologics
  • Acitretin plus phototherapy
  • Class 1 topical corticosteroid + etanercept
  • Calcipotriene/betamethasone + adalimumab 1

Psoriatic Arthritis

• Early treatment recommended to prevent joint damage:
  • NSAIDs for mild disease
  • DMARDs for moderate disease
  • TNF inhibitors for moderate-severe disease 1

Safety Precautions with Biologics

• Before initiating: Screen for tuberculosis
• During treatment: Monitor for serious infections
• Boxed warnings for adalimumab: Serious infections (including TB, bacterial sepsis, invasive fungal infections) and malignancy risk 3
• Discontinue if serious infection or sepsis develops 3

Pediatric Considerations

• Use lower potency corticosteroids
• Specific dosing for biologics based on weight (see adalimumab pediatric dosing) 3

Monitoring and Follow-up

• Assess treatment response after 4 weeks
• Monitor for adverse effects:
  • Topical corticosteroids: Skin atrophy, telangiectasia, striae
  • Methotrexate: Liver function abnormalities
  • Biologics: Infections, injection site reactions 1

Common Pitfalls to Avoid

1. Abrupt discontinuation of systemic corticosteroids can precipitate erythrodermic or pustular psoriasis; always taper gradually 1
2. Medication interactions: Certain medications can worsen psoriasis, including alcohol, beta-blockers, NSAIDs, lithium, chloroquine, and mepacrine 1
3. Vitamin D analog overdose: Maximum 100g per week to avoid hypercalcemia 1
4. Inadequate TB screening before biologic therapy 3

The treatment landscape for psoriasis has evolved significantly with the development of highly targeted therapies, particularly biologics, which have demonstrated excellent efficacy and acceptable safety profiles for moderate to severe disease 2, 4. For mild disease, topical therapies remain the cornerstone of treatment 2.