What are the treatment options for psoriasis?

Treatment Options for Psoriasis

For psoriasis treatment, biologics targeting IL-17 or IL-23 pathways are the most effective options for moderate-to-severe disease, while combination therapy with potent corticosteroids and vitamin D analogs is recommended for mild disease. 1

Disease Classification and Treatment Approach

Psoriasis treatment is guided by disease severity:

• Mild disease (<10% body surface area [BSA])
• Moderate-to-severe disease (≥10% BSA or significant impact on quality of life) 1

First-Line Treatment Options

For Mild Psoriasis (< 10% BSA):

1. Topical Therapy:

   • First choice: Combination of potent corticosteroid with vitamin D analog (calcipotriene/calcipotriol) 1

     • Provides synergistic effects
     • Reduces corticosteroid-related side effects
     • Extends treatment benefit and remission
     • Maximum 100g of vitamin D analogs weekly to avoid hypercalcemia

   • Topical corticosteroid options by potency class:

     • 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

   • Other topical options:

     • Tazarotene (topical retinoid) - contraindicated in pregnancy (category X) 1
     • Calcineurin inhibitors (tacrolimus, pimecrolimus) - particularly effective for facial and intertriginous psoriasis 1
     • Medicated shampoos with coal tar, salicylic acid for scalp psoriasis 1

For Moderate-to-Severe Psoriasis (≥10% BSA):

1. Biologic Therapy (first-line for moderate-to-severe disease):

   • IL-17 inhibitors - higher efficacy for skin involvement than TNF inhibitors 1
   • IL-23 inhibitors - excellent efficacy and safety profiles 1
   • TNF-α inhibitors (e.g., adalimumab) - particularly effective when psoriatic arthritis is present 1, 2
   • IL-12/23 inhibitors - effective for both skin and joint manifestations 1

2. Phototherapy:

   • Narrowband UVB - first-line phototherapy option 1
   • PUVA (psoralen plus UVA) - option if narrowband UVB is inadequate 1
   • Targeted phototherapy (308-nm excimer laser) - for localized lesions and resistant areas 1

3. Systemic Oral Agents:

   • Methotrexate - 10-15 mg weekly starting dose, requires monitoring of CBC, liver function, and renal function 1
   • Cyclosporine - rapid control of severe psoriasis but limited to short-term use due to nephrotoxicity 1
   • Acitretin - oral retinoid, more effective for pustular psoriasis variants, contraindicated in women of childbearing potential 1
   • JAK inhibitors - oral agents blocking multiple cytokine pathways 1
   • PDE4 inhibitors (apremilast) - moderate efficacy with favorable safety profile 1

Specific Biologic Treatment Details

For moderate-to-severe plaque psoriasis, adalimumab (Humira) is administered as follows:

• Initial dose: 80 mg
• Maintenance: 40 mg every other week starting one week after initial dose 2

Important safety considerations for biologics:

• Increased risk of serious infections including tuberculosis
• Risk of malignancy, including lymphoma
• Requires TB testing before initiation 2

Special Populations

• Pediatric patients: Use lower potency corticosteroids 1
• Psoriatic arthritis: Early treatment recommended to prevent joint damage
  • NSAIDs for mild disease
  • DMARDs for moderate disease
  • TNF inhibitors for moderate-severe disease 1

Treatment Monitoring

• Evaluate response after 4 weeks for topical therapy
• Limit potent corticosteroid use to 4 weeks to minimize skin atrophy risk
• Regular monitoring for adverse effects:
  • Corticosteroids: skin atrophy, telangiectasia, striae
  • Methotrexate: hepatotoxicity, bone marrow suppression
  • Biologics: infections, injection site reactions 1

Maintenance Therapy

Proactive maintenance therapy after achieving disease control is recommended to prevent relapses, using combination products or separate products with corticosteroid in the morning and vitamin D analog in the evening 1

Treatment Algorithm

1. Assess disease severity (BSA and impact on quality of life)
2. For mild disease: Start with topical combination therapy (corticosteroid + vitamin D analog)
3. For moderate-to-severe disease or inadequate response to topicals:
   • First choice: Biologic therapy (IL-17 or IL-23 inhibitors preferred)
   • Alternative options: Phototherapy, systemic oral agents
4. For psoriatic arthritis: Add TNF inhibitor or other appropriate agent
5. Monitor response and adjust therapy as needed