What is the recommended treatment for a plaque psoriasis flare?

Treatment of Plaque Psoriasis Flares

For plaque psoriasis flares, the most effective first-line treatment is a combination of potent corticosteroids with vitamin D analogs, which provides superior efficacy compared to either agent alone. 1

First-Line Treatment Options

Topical Therapy (for localized disease <10% BSA)

• Combination therapy:

  • Potent corticosteroid + vitamin D analog (calcipotriene/calcipotriol)
  • Apply once daily for rapid improvement within 2 weeks 1
  • For separate products: apply corticosteroid in morning and vitamin D analog in evening 1

• Potency selection based on location:

  • Body/extremities: Class 1-2 (high-potency) corticosteroids
  • Face/intertriginous areas: Class 6-7 (low-potency) corticosteroids or calcineurin inhibitors 1
  • Scalp: Solutions or foams of corticosteroids or vitamin D analogs 1

Duration and Maintenance

• Limit potent corticosteroid use to 4 weeks to minimize skin atrophy risk 1
• Transition to maintenance therapy after initial control:
  • Weekend-only application of corticosteroid
  • Vitamin D analog 5 days per week 1

Second-Line Options (for inadequate response to topicals)

Phototherapy

• Narrowband UVB is first-line phototherapy option 2
• PUVA should be considered if NB-UVB has not been adequately effective 3
• Bath PUVA and oral PUVA are both effective options for psoriasis 3

Systemic Non-Biologic Therapy

• 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
• Apremilast: Oral option that doesn't require laboratory monitoring, but has slower onset and lower clearance rates 3

Biologic Therapy (for moderate-severe disease)

• Recommended for moderate-to-severe plaque psoriasis as first-line treatment 3

• Options include:

  • TNF-α inhibitors (infliximab, etanercept, adalimumab)
  • IL-17 inhibitors (secukinumab, ixekizumab)
  • IL-23 inhibitors (guselkumab, tildrakizumab) 2
  • IL-12/23 inhibitor (ustekinumab)

• For severe flares/erythrodermic psoriasis: Infliximab has shown dramatic response 4

  • Recommended starting dose: 5 mg/kg at weeks 0,2, and 6, then every 8 weeks 3

Special Considerations

Scalp Psoriasis

• Medicated shampoos containing coal tar, salicylic acid
• Solutions or foams of corticosteroids or vitamin D analogs 1
• Infliximab can be recommended for moderate-to-severe scalp involvement 3

Pediatric Patients

• Use lower potency corticosteroids
• Calcipotriene/calcipotriol is recommended for childhood plaque psoriasis 3
• Avoid occlusion with vitamin D analogs due to risk of hypercalcemia 3

Common Pitfalls to Avoid

1. Abrupt discontinuation: Potential for rebound flare if high-potency corticosteroids are abruptly discontinued 3
2. Overuse of potent corticosteroids: Can lead to skin atrophy, telangiectasia, and striae 1
3. Inadequate maintenance: Reactive rather than proactive management leads to more frequent relapses 5
4. Inappropriate biologic switching: Direct switching between certain biologics (e.g., efalizumab to etanercept) can provoke paradoxical flaring 4

Treatment Algorithm

1. Mild-moderate localized disease: Start with topical combination therapy
2. If inadequate response after 4 weeks: Consider phototherapy or systemic therapy
3. Moderate-severe disease: Consider biologics or systemic agents as first-line options
4. For severe/erythrodermic flares: Consider infliximab or cyclosporine for rapid control

Proactive maintenance therapy after achieving disease control is crucial to prevent relapses and maintain remission, as reactive management leads to more frequent flares and potentially worse symptoms upon relapse 5.