What are the current treatment guidelines for psoriasis?

Current Guidelines for Treatment of Psoriasis

For psoriasis treatment, the American Academy of Dermatology and National Psoriasis Foundation recommend a stepwise approach based on disease severity, with biologics targeting IL-17 or IL-23 pathways being the most effective for moderate-to-severe disease, while combination therapy with potent corticosteroids and vitamin D analogs is recommended as first-line treatment for mild disease. 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 Algorithm by Disease Severity

Mild Psoriasis (First-Line Options)

1. Topical Therapy:

   • Combination of potent corticosteroids with vitamin D analogs (calcipotriene/calcipotriol) is strongly recommended, providing synergistic effects and reducing corticosteroid-related side effects 1, 2
   • Maximum of 100g of vitamin D analogs weekly to avoid hypercalcemia 2
   • Topical corticosteroid potency should be selected based on treatment area:
     • High-potency for trunk and extremities
     • Lower-potency for face, intertriginous areas, and genitalia 2

2. Topical Retinoids:

   • Tazarotene is effective but may cause irritation; best used in combination with corticosteroids 2, 1
   • Contraindicated in pregnancy (category X) 1

3. Calcineurin Inhibitors:

   • Tacrolimus and pimecrolimus are particularly effective for facial and intertriginous psoriasis 2, 1
   • No risk of skin atrophy, but may cause burning sensation initially 1

Moderate-to-Severe Psoriasis (First-Line Options)

1. Biologic Therapy:

   • IL-17 inhibitors have higher efficacy for skin involvement than TNF inhibitors 2, 1
   • IL-23 inhibitors offer excellent efficacy and safety profiles 1
   • TNF-α inhibitors (e.g., adalimumab) are particularly beneficial when psoriatic arthritis is present 1, 3
   • IL-12/23 inhibitors are effective for both skin and joint manifestations 1

2. Phototherapy:

   • Narrowband UVB is the preferred phototherapy option 1
   • PUVA (psoralen plus UVA) is recommended when narrowband UVB is inadequate 1
   • 308-nm excimer laser is effective for localized lesions and resistant areas 2, 1

3. Oral Systemic Agents:

   • Methotrexate: 10-15 mg weekly, requires monitoring of CBC, liver function, and renal function 1
   • Cyclosporine: Provides rapid control but limited to short-term use due to nephrotoxicity 1
   • JAK inhibitors: Oral agents that block multiple cytokine pathways 1
   • PDE4 inhibitors (e.g., apremilast): Moderate efficacy but favorable safety profile 1
   • Acitretin: Less effective as monotherapy but more effective for pustular variants; contraindicated in women of childbearing potential 1

Special Considerations

Inverse Psoriasis

• Affects intertriginous areas (axillae, inframammary, abdominal, inguinal, gluteal folds, groin, genitalia) 2
• Typically erythematous, less indurated, well-demarcated with minimal scale 2
• First-line treatment: Topical calcineurin inhibitors (tacrolimus) or low-potency corticosteroids 2

Scalp Psoriasis

• Use medicated shampoos containing coal tar, salicylic acid, and solutions/foams of corticosteroids or vitamin D analogs 1
• Targeted phototherapy with 308-nm excimer laser for resistant areas 2, 1

Pediatric Psoriasis

• Use lower potency corticosteroids 1
• Biologics approved for specific age groups (e.g., adalimumab for plaque psoriasis in appropriate candidates) 3

Psoriatic Arthritis

• Early treatment to prevent joint damage 1
• TNF inhibitors are particularly effective for both skin and joint manifestations 1, 3

Treatment Monitoring and Maintenance

• Evaluate response after 4 weeks for topical therapy 1
• Limit potent corticosteroid use to 4 weeks to minimize risk of skin atrophy 1
• Regular monitoring for adverse effects:
  • Skin atrophy, telangiectasia, and striae with corticosteroids
  • Hepatotoxicity and bone marrow suppression with methotrexate
  • Infections and injection site reactions with biologics 1
• Proactive maintenance therapy after achieving disease control to prevent relapses 1

Common Pitfalls and Caveats

• Avoid prolonged use of high-potency corticosteroids on face, intertriginous areas, and genitalia due to increased risk of atrophy 2
• Do not exceed 100g of vitamin D analogs weekly to avoid hypercalcemia 2
• Monitor for serious infections and malignancy with biologic therapy, particularly TNF inhibitors 3
• Consider combination therapy to enhance efficacy and reduce side effects 2, 1
• Recognize that genital psoriasis causes significant psychological impact and requires special attention 2