What are the treatment options for plaque psoriasis?

Treatment Options for Plaque Psoriasis

The most effective treatment approach for plaque psoriasis depends on disease severity, with topical corticosteroids combined with vitamin D analogs being first-line for mild-to-moderate disease, while biologics targeting TNF-α, IL-17, or IL-23 are recommended as first-line options for moderate-to-severe disease. 1

Disease Classification and Initial Assessment

• Disease severity classification:

  • Mild: <10% body surface area (BSA)
  • Moderate-to-severe: ≥10% BSA or significant impact on quality of life

• Key assessment factors:

  • BSA involvement
  • Impact on quality of life
  • Presence of psoriatic arthritis (occurs in 25-30% of patients) 2
  • Associated comorbidities (cardiovascular disease, metabolic syndrome) 1, 3

Treatment Algorithm Based on Disease Severity

Mild Plaque Psoriasis (<10% BSA)

1. First-line: Topical therapies 1, 4

   • Combination of potent corticosteroids with vitamin D analogs is superior to either agent alone 1

     • Apply corticosteroid in morning, vitamin D analog in evening
     • Available as separate products or combination formulations

   • Topical corticosteroids:

     • Potency classes:
       • Class 1 (Ultrahigh-potency): Clobetasol propionate, Halobetasol propionate
       • Class 2-5 (High to moderate potency): Betamethasone dipropionate, Triamcinolone acetonide
       • Class 6-7 (Low potency): Hydrocortisone, Desonide 1
     • Use high-potency for trunk/limbs, lower potency for face/intertriginous areas
     • Limit use to 2-4 weeks to prevent skin atrophy 1

   • Vitamin D analogs (calcipotriene/calcipotriol):

     • Less effective than potent corticosteroids but no risk of skin atrophy 5
     • Can cause skin irritation in some patients

2. Alternative topical options:

   • Tazarotene (topical retinoid):

     • Efficacy comparable to mid-potency corticosteroids
     • Best used in combination with corticosteroids to reduce irritation 2, 1
     • Pregnancy category X (contraindicated) 2

   • Calcineurin inhibitors (tacrolimus, pimecrolimus):

     • Particularly effective for facial and intertriginous psoriasis 2, 4
     • No risk of skin atrophy
     • May cause burning/stinging sensation initially

   • Other agents (less commonly used):

     • Salicylic acid: Useful for thick plaques as a keratolytic 4
     • Coal tar and anthralin: Limited benefit compared to other options 5

Moderate-to-Severe Plaque Psoriasis (≥10% BSA)

1. First-line: Biologics 2, 1, 3

   • TNF-α inhibitors:

     • Adalimumab: Indicated for moderate-to-severe plaque psoriasis 6
     • Infliximab: Recommended as monotherapy for moderate-to-severe plaque psoriasis (strength of recommendation: A) 2
       • Starting dose: 5 mg/kg at weeks 0,2, and 6, then every 8 weeks
       • Can be used for palmoplantar, nail, and scalp psoriasis

   • IL-17 inhibitors (secukinumab, ixekizumab, brodalumab) 3

   • IL-23 inhibitors (guselkumab, tildrakizumab, risankizumab) 3

2. Traditional systemic therapies:

   • Methotrexate:

     • Starting dose: 10-15 mg weekly
     • Requires monitoring of CBC, liver function, renal function 1
     • Can be combined with infliximab to augment efficacy 2

   • Cyclosporine:

     • Rapid control of severe psoriasis (2.5-5.0 mg/kg/day)
     • Limited to short-term use due to nephrotoxicity 1

   • Acitretin:

     • Less effective as monotherapy
     • More effective for pustular variants
     • Contraindicated in women of childbearing potential (teratogenic) 1

   • Apremilast (phosphodiesterase-4 inhibitor):

     • Oral small molecule
     • May be combined with infliximab when clinically indicated 2, 3

3. Phototherapy:

   • Narrowband UVB:

     • First-line phototherapy option 1, 3
     • Can be combined with topical treatments

   • PUVA (psoralen plus UVA):

     • Option if narrowband UVB is inadequate
     • Available as bath PUVA or oral PUVA 1

Special Considerations

Scalp Psoriasis

• Corticosteroid solutions, foams, or shampoos are more effective than vitamin D analogs 1, 7
• Medicated shampoos containing salicylic acid or coal tar can be helpful 1

Facial and Intertriginous Psoriasis

• Low-potency corticosteroids or calcineurin inhibitors are preferred 2, 4
• Avoid long-term corticosteroid use in these sensitive areas

Psoriatic Arthritis

• Infliximab is recommended for psoriasis of any severity when associated with significant psoriatic arthritis (strength of recommendation: A) 2
• TNF-α inhibitors, IL-17 inhibitors, and IL-23 inhibitors are effective for both skin and joint manifestations 3

Monitoring and Maintenance

• Evaluate treatment response after 4 weeks for topical therapy 1
• Limit potent corticosteroid use to 4 weeks to minimize risk of skin atrophy 1
• For maintenance after disease control:
  • Weekend-only application of corticosteroid
  • Vitamin D analog 5 days per week 1
• Regular monitoring for adverse effects:
  • Corticosteroids: skin atrophy, telangiectasia, striae
  • Methotrexate: hepatotoxicity, bone marrow suppression
  • Biologics: infections, injection site reactions 1, 6

Treatment Pitfalls to Avoid

1. Overuse of potent corticosteroids leading to skin atrophy
2. Inadequate treatment of moderate-to-severe disease with topicals alone
3. Failure to recognize and address psoriatic arthritis
4. Not considering comorbidities when selecting treatment
5. Poor adherence due to complex topical regimens

By following this evidence-based approach and selecting treatments based on disease severity, location, and patient factors, optimal management of plaque psoriasis can be achieved.