What is the primary care treatment for severe whole body psoriasis?

Primary Care Treatment for Severe Whole Body Psoriasis

For severe whole body psoriasis, referral to a dermatologist for systemic therapy is strongly recommended, with methotrexate being the most appropriate first-line systemic agent due to its efficacy, safety profile, and cost-effectiveness. 1

Initial Assessment and Treatment Decision

When evaluating a patient with severe whole body psoriasis:

• Assess body surface area (BSA) involvement (severe typically >10%)
• Evaluate impact on quality of life
• Check for psoriatic arthritis symptoms
• Screen for comorbidities (metabolic syndrome, cardiovascular disease)

First-Line Topical Therapy (While Awaiting Specialist Referral)

For immediate symptom relief while arranging specialist care:

• Potent to ultra-potent topical corticosteroids (Class 1-2) for short-term use (2-4 weeks) 1

  • Examples: clobetasol propionate 0.05%, halobetasol propionate 0.05%
  • Apply once or twice daily to affected areas
  • Limit to 50g/week of ultra-potent steroids to minimize systemic absorption

• Combination with vitamin D analogs (calcipotriene/calcipotriol) 2

  • Provides superior efficacy compared to either agent alone
  • Can be used as fixed combination products or separately (steroid in morning, vitamin D analog in evening)

Systemic Therapy Options (Specialist-Directed)

First-Line Systemic Agents

1. Methotrexate

   • Most commonly prescribed traditional systemic therapy worldwide 1
   • Starting dose: 10-15 mg weekly (oral or parenteral) 3
   • Therapeutic dose: 15-20 mg weekly 3
   • Maximum dose: 25 mg weekly 4
   • Response typically seen within 8 weeks 3
   • Requires monitoring: CBC, liver function tests, renal function
   • Contraindications: pregnancy, liver disease, significant renal impairment

2. Cyclosporine

   • Highly effective for rapid control of severe psoriasis 1
   • Dosing: 2.5-5.0 mg/kg/day in two divided doses 1
   • Limited to short-term use (3-4 months in US, up to 2 years in UK) 1
   • Particularly effective for erythrodermic psoriasis 1
   • Requires monitoring: blood pressure, renal function, lipids
   • Contraindications: abnormal renal function, uncontrolled hypertension

3. Acitretin

   • Oral retinoid, less effective as monotherapy than other systemic agents 1
   • More effective for pustular psoriasis variants
   • Dosing: starting at 10-25 mg daily
   • Absolutely contraindicated in women of childbearing potential (teratogenic) 1

Biologic Agents (Second-Line or Specialist-Initiated)

For patients with inadequate response to traditional systemics:

• Adalimumab (TNF inhibitor) 5
  • Indicated for moderate to severe chronic plaque psoriasis
  • Can be used alone or in combination with methotrexate
  • Requires TB screening and monitoring for infections

Treatment Algorithm

1. Initial approach:

   • Start potent topical corticosteroids + vitamin D analog while arranging referral
   • Consider short-term oral prednisone taper only for severe flares (not for long-term use)

2. First systemic agent (specialist-directed):

   • Methotrexate 15 mg weekly (oral or subcutaneous) for most patients
   • If rapid control needed or erythrodermic presentation: consider cyclosporine

3. Inadequate response after 8-12 weeks:

   • Increase methotrexate dose up to 20-25 mg weekly 4
   • Consider switching to alternative systemic agent
   • Consider combination therapy (methotrexate + cyclosporine) for recalcitrant cases 6

4. Maintenance after control achieved:

   • Taper methotrexate gradually rather than abrupt cessation 7
   • Consider weekend-only application of topical agents for maintenance

Important Considerations and Pitfalls

• Avoid abrupt discontinuation of systemic therapy, which leads to higher relapse rates 7
• Recognize psoriasis as a systemic inflammatory disease with associated comorbidities
• Monitor for hepatotoxicity with methotrexate, especially in patients with obesity or metabolic syndrome 1
• Limit cyclosporine duration to prevent irreversible nephrotoxicity 1
• Consider phototherapy (NB-UVB or PUVA) as an alternative or adjunct to systemic therapy 2
• Avoid combination of cyclosporine with phototherapy due to increased skin cancer risk 1

For patients with severe psoriasis affecting quality of life, early referral to dermatology is crucial while initiating appropriate topical therapy to provide symptomatic relief during the interim period.