What are the treatment options for psoriasis?

Treatment Options for Psoriasis

The most effective approach to psoriasis treatment involves a stepwise algorithm based on disease severity, with topical therapies for mild disease, phototherapy for moderate disease, and systemic or biologic agents for severe or refractory cases. 1

Assessment of Psoriasis Severity

• Mild psoriasis: Limited body surface area involvement, typically treated with topical therapies
• Moderate-to-severe psoriasis: Extensive involvement or disease resistant to topical therapy, requiring phototherapy or systemic treatments
• Special areas: Ear, scalp, intertriginous regions, and face require specialized approaches

First-Line Topical Therapies

Topical Corticosteroids

• Low-potency (class 6-7) corticosteroids (e.g., hydrocortisone 1%):

  • Recommended for sensitive areas (face, intertriginous areas, ears)
  • Apply 1-2 times daily for 2-4 weeks 1
  • Avoid high-potency corticosteroids in these areas due to risk of skin atrophy

• Medium to high-potency corticosteroids:

  • For thicker plaques on extremities, trunk, and scalp
  • Limit duration to 4 weeks to prevent adverse effects 1

Vitamin D Analogs

• Calcipotriene (calcipotriol)
• Can be used alone or in combination with corticosteroids
• Particularly effective for maintenance therapy after initial control with corticosteroids 1

Calcineurin Inhibitors

• Tacrolimus 0.1% and pimecrolimus
• Ideal for long-term treatment of sensitive areas without risk of skin atrophy
• Apply 1-2 times daily 1
• Particularly effective for facial and intertriginous psoriasis 2

Other Topical Options

• Tazarotene: Effective for stable plaque psoriasis, usually combined with corticosteroids 2
• Salicylic acid: Used as a keratolytic to enhance penetration of other medications 2
• Coal tar and anthralin: Less commonly used but effective options for resistant cases 3, 2

Scalp Psoriasis Management

• Medicated shampoos containing coal tar, salicylic acid
• Solutions or foams of corticosteroids or vitamin D analogs 1
• Gentle removal of scales to improve medication penetration

Phototherapy

• Consider adding phototherapy if inadequate response to topical therapy alone 1
• UVB therapy is effective for widespread disease
• Avoid commercial tanning beds as they are rarely effective and can cause significant side effects 1

Systemic Therapies for Moderate-to-Severe Disease

Conventional Systemic Agents

• Methotrexate:

  • Most widely used systemic agent
  • Cost-effective with long safety data
  • Dosage: 7.5-25 mg weekly 1

• Cyclosporine:

  • Particularly effective for erythrodermic psoriasis
  • Dosage: 3-5mg/kg/day for short courses (3-4 months) 1

Biologic Therapies

• TNF inhibitors (e.g., adalimumab):

  • For moderate-to-severe plaque psoriasis
  • Adalimumab dosing for adults: 80 mg initial dose, followed by 40 mg every other week starting one week after initial dose 1, 4
  • Monitor for serious infections and malignancy risk 4

• IL-17 inhibitors and IL-12/23 inhibitors:

  • Can be used as first-line therapy for moderate-to-severe psoriasis 1

Special Considerations

Psoriasis in the Ear

• Low-potency topical corticosteroids
• Gentle ear canal cleaning to remove scales
• Consider ENT referral for recurrent attacks with hearing impairment 1

Pediatric Patients

• Use lower potency corticosteroids
• Adjust dosing of biologics based on weight 1, 4
• For juvenile idiopathic arthritis with psoriasis, follow weight-based dosing guidelines 4

Psoriatic Arthritis

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

Treatment Strategies to Improve Outcomes

Combination Therapy

• Corticosteroids + vitamin D analogs: Enhanced efficacy with reduced side effects 5
• Initial bitherapy followed by maintenance monotherapy can be effective 5

Rotational or Sequential Therapy

• Alternating different medication classes to minimize side effects
• Weekend-only application of corticosteroids may be effective for maintenance 3

Monitoring and Follow-up

• Evaluate treatment response after 4 weeks 1
• Regular monitoring for:
  • Skin atrophy and telangiectasia with topical corticosteroids
  • Serious infections with biologics
  • Liver function abnormalities with methotrexate

Common Pitfalls to Avoid

• Prolonged use of high-potency corticosteroids on sensitive areas
• Inadequate treatment duration (most topicals require 6-8 weeks for full effect)
• Starting biologics in patients with active infections 4
• Poor adherence to topical regimens (simplify regimens when possible) 6