What are the treatment options for psoriasis?

Treatment Options for Psoriasis

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

Disease Classification and Treatment Selection

Psoriasis severity is classified based on body surface area (BSA) involvement:

• Mild disease: <10% BSA
• Moderate-to-severe disease: ≥10% BSA or significant impact on quality of life 1

Treatment selection follows this algorithm:

Mild Psoriasis (<10% BSA)

1. First-line: Topical Therapy

   • Combination therapy: Potent corticosteroid + vitamin D analog (calcipotriene/calcipotriol)

     • Provides synergistic effects
     • Reduces corticosteroid-related side effects
     • Extends treatment benefit and remission
     • Maximum 100g of vitamin D analogs weekly (to avoid hypercalcemia) 1

   • Topical corticosteroids 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
     • Caution: Limit potent corticosteroid use to 4 weeks to minimize skin atrophy risk 1

   • Alternative topicals:

     • Tazarotene: Efficacy comparable to mid-potency corticosteroids (contraindicated in pregnancy) 1
     • Calcineurin inhibitors (tacrolimus, pimecrolimus): Particularly effective for facial and intertriginous psoriasis with no risk of skin atrophy 1
     • For scalp psoriasis: Medicated shampoos with coal tar, salicylic acid, or solutions/foams of corticosteroids/vitamin D analogs 1

2. If inadequate response to topicals: Phototherapy

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

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

1. First-line: Biologic Therapy

   • IL-17 inhibitors: Highest efficacy for skin involvement, strongly recommended for skin and nail psoriasis 1
   • IL-23 inhibitors: Excellent efficacy and safety profiles, strongly recommended for skin and nail disease 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. Alternative Systemic Therapies

   • JAK inhibitors: Oral agents that block multiple cytokine pathways 1
   • PDE4 inhibitors (e.g., apremilast): Moderate efficacy but favorable safety profile 1
   • Traditional systemics:
     • Methotrexate: 10-15 mg weekly starting dose, requires monitoring of CBC, liver function, and renal function 1
     • Cyclosporine: Rapid control but 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 1

Monitoring and Maintenance

• Evaluate treatment response after 4 weeks for topical therapy 1

• Monitor for adverse effects:

  • Corticosteroids: Skin atrophy, telangiectasia, striae
  • Methotrexate: Hepatotoxicity, bone marrow suppression
  • Biologics: Infections, injection site reactions 1, 2
  • Adalimumab (TNF blocker): Serious infections including TB, malignancy risk 2

• Proactive maintenance therapy after achieving control:

  • Use combination products or separate products with corticosteroid in morning and vitamin D analog in evening 1

Special Populations

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

Treatment Pitfalls to Avoid

1. Overuse of potent corticosteroids: Limit to 4 weeks to prevent skin atrophy
2. Inadequate monitoring of systemic therapies (especially methotrexate and biologics)
3. Failure to screen for TB before starting TNF blockers like adalimumab 2
4. Ignoring comorbidities when selecting therapy (e.g., psoriatic arthritis presence should guide toward TNF inhibitors)
5. Not considering maintenance therapy after achieving disease control

The American Academy of Dermatology's treatment approach represents the most current evidence-based guidance, emphasizing the importance of matching treatment intensity to disease severity while considering safety profiles and patient-specific factors.