What are the treatment options for psoriasis?

Treatment Options for Psoriasis

For the treatment of psoriasis, a stepwise approach based on disease severity is recommended, with topical corticosteroids being the first-line treatment for mild disease, while moderate to severe disease requires phototherapy or systemic agents including biologics. 1

Treatment Based on Disease Severity

Mild Psoriasis (Less than 10% Body Surface Area)

• First-line: Topical Corticosteroids

  • Start with moderate potency (class III-IV) corticosteroids for the body 1
  • Limit use to 4 weeks to minimize skin atrophy risk 1
  • For sensitive areas (face, genitals, intertriginous areas), use low-potency steroids 1

• Combination Therapy

  • Vitamin D analog + topical corticosteroid is superior to either agent alone 1
  • Provides better maintenance of therapeutic effect after discontinuation 1

• Other Topical Options

  • Coal tar preparations: Start with 0.5-1.0% concentration in petroleum jelly, gradually increase to maximum 10% 1
  • Topical dithranol: "Short contact mode" (15-45 minutes daily), starting at 0.1-0.25% concentration 1
  • Calcineurin inhibitors (tacrolimus, pimecrolimus): Useful for facial and intertriginous psoriasis 2

Moderate to Severe Psoriasis (≥5% Body Surface Area or Affecting Special Sites)

• Phototherapy

  • UVB or PUVA (psoralen plus UVA) 3
  • Consider for patients with inadequate response to topical therapy 1
  • Home UV phototherapy is an alternative for appropriate patients 3

• Traditional Systemic Agents

  • Methotrexate: Most widely used systemic agent, 7.5-25 mg weekly 1
  • Cyclosporine: Particularly effective for erythrodermic psoriasis, 3-5mg/kg/day for short courses (3-4 months) 1
  • Acitretin: Oral retinoid, often used in combination with phototherapy 3

• Biologic Agents (for moderate-severe disease unresponsive to other therapies)

  • TNF inhibitors (e.g., adalimumab): For plaque psoriasis, initial dose of 80 mg, followed by 40 mg every other week 4
  • IL-17 inhibitors
  • IL-12/23 inhibitors 1

Special Considerations

Scalp Psoriasis

• Medicated shampoos containing coal tar, salicylic acid
• Solutions or foams of corticosteroids or vitamin D analogs 1
• Salicylic acid can help with thick plaques to increase absorption of other medications 2

Pediatric Patients

• Use lower potency corticosteroids 1
• For juvenile idiopathic arthritis with psoriasis, adalimumab dosing is weight-based:
  • 10-15 kg: 10 mg every other week
  • 15-30 kg: 20 mg every other week
  • ≥30 kg: 40 mg every other week 4

Psoriatic Arthritis

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

Treatment Strategies for Long-term Management

Rotational Therapy

• Rotating between different treatment modalities every 1-2 years may minimize cumulative toxicity 5
• Allows effective treatments to be maintained for many years by providing "drug holidays" 5

Combination Therapy

• Often more effective and safer than single-agent therapy 6
• Combining agents with complementary adverse effect profiles is preferable 6
• Synergistic enhancement is seen with most paired combinations of acitretin, phototherapy, cyclosporine, and methotrexate 6
• Caution: Cyclosporine + PUVA is contraindicated due to increased cancer risk 6

Monitoring and Follow-up

• Evaluate treatment response after 4 weeks of topical therapy 1
• Monitor for local adverse effects:
  • Corticosteroids: skin atrophy, telangiectasia, striae
  • Vitamin D analogs: irritation and burning sensation 1
• For biologics like adalimumab, monitor for serious infections and malignancy 4
• Regular follow-up is necessary to assess disease control and medication side effects 1

Common Pitfalls to Avoid

1. Overuse of potent topical corticosteroids - can lead to skin atrophy, telangiectasia, and tachyphylaxis
2. Inadequate patient education - proper application techniques are essential for treatment adherence
3. Failure to recognize psoriatic arthritis - occurs in up to 30% of psoriasis patients and requires systemic therapy
4. Neglecting quality of life impact - psoriasis can significantly affect psychological wellbeing and should be addressed
5. Not adjusting treatment based on response - treatment should be escalated if inadequate response after appropriate trial