What is the best treatment for psoriasis?

Best Treatment for Psoriasis

For psoriasis treatment, combination therapy with vitamin D analogues and topical corticosteroids is recommended as the first-line treatment for mild to moderate plaque psoriasis, with vitamin D analogues recommended for long-term use up to 52 weeks. 1

Treatment Algorithm Based on Disease Severity

Mild to Moderate Psoriasis

1. First-line therapy:

   • Combination of vitamin D analogues (calcipotriene/calcitriol) with topical corticosteroids 1
   • Recommended regimens:
     • Morning corticosteroid + evening vitamin D analogue
     • Vitamin D analogues twice daily on weekdays + corticosteroids twice daily on weekends for maintenance

2. Topical Corticosteroid Selection:

   • Choose based on location:
     • Low potency (Class 6-7): Face and intertriginous areas
     • Medium potency (Class 3-5): Body
     • High/ultrahigh potency (Class 1-2): Thick plaques 1
   • Limit duration to 4 weeks for most areas 1
   • Maximum 50g weekly for ultrahigh potency agents 1

3. Vitamin D Analogues:

   • Can be used for long-term therapy (up to 52 weeks) 2, 1
   • Apply after phototherapy to prevent inactivation 2
   • Maximum 100g weekly to avoid hypercalcemia 1

4. Scalp Psoriasis:

   • Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 2
   • Medicated shampoos containing coal tar, salicylic acid, or solutions/foams of corticosteroids 1

Moderate to Severe Psoriasis

1. Phototherapy:

   • Narrowband UVB 2-3 times weekly for 20-30 sessions 1
   • PUVA as alternative if NB-UVB ineffective (higher skin cancer risk) 1

2. Systemic Therapy:

   • Methotrexate: 7.5-25 mg weekly 1
   • Cyclosporine: 3-5mg/kg/day for short courses (3-4 months), particularly effective for erythrodermic psoriasis 1
   • Acitretin: Particularly effective for pustular forms (avoid during pregnancy) 1

3. Biologic Agents:

   • TNF inhibitors (adalimumab): For moderate to severe plaque psoriasis 3
   • IL-17 inhibitors and IL-12/23 inhibitors as first-line therapy 1
   • Apremilast (PDE4 inhibitor) for patients with history of malignancy 1

Special Considerations

Vehicle Selection

The vehicle choice significantly impacts treatment adherence and efficacy. While ointments are traditionally considered most potent due to their occlusive nature, studies show that other formulations of clobetasol propionate (solutions, foams, creams) can be equally effective 4. Choose vehicles based on:

• Patient preference (critical for adherence)
• Location of lesions (foams/solutions for scalp, creams for face, ointments for thick plaques)

Combination Strategies

• Avoid simultaneous use of salicylic acid with calcipotriene (acidic pH inactivates calcipotriene) 1
• Salicylic acid can be used with other topical therapies to increase absorption into thick plaques 5
• Tacrolimus and pimecrolimus are useful for facial and intertriginous psoriasis 5

Monitoring and Follow-up

• Evaluate treatment response after 4 weeks 1
• Consider adding phototherapy if inadequate response to topical therapy alone 1
• Monitor for adverse effects such as skin atrophy, telangiectasia, and systemic absorption 1

Cautions and Pitfalls

• Avoid oral systemic corticosteroids due to risk of disease flares during/after tapering 1
• Be aware of potential side effects of biologics including serious infections and malignancy risk 3
• Long-term use of topical corticosteroids can lead to skin atrophy, telangiectasia, and systemic absorption 2
• Rotate treatment sites and use combination therapy to minimize corticosteroid side effects 1

The treatment approach should be adjusted based on disease severity, location, and response to therapy, with combination therapy offering the best balance of efficacy and safety for most patients with psoriasis.