What are the treatment options for psoriasis?

Psoriasis Treatment Options

The most effective approach to psoriasis treatment follows a stepwise algorithm based on disease severity, with topical therapy combining potent corticosteroids and vitamin D analogs as first-line for mild disease, and biologics (particularly IL-17 and IL-23 inhibitors) recommended as first-line for moderate-to-severe psoriasis. 1

Treatment Algorithm Based on Disease Severity

Mild Psoriasis (Limited Body Surface Area)

1. First-line: Topical Therapy

   • Combination therapy: Potent corticosteroid + vitamin D analog (provides synergistic effects and reduces corticosteroid side effects) 1
   • Corticosteroid selection by area:
     • Trunk/extremities: High-potency (Class 2-5) corticosteroids
     • Face/intertriginous/genital areas: Low-potency (Class 6-7) corticosteroids 1
   • Vitamin D analogs: Maximum 100g weekly to avoid hypercalcemia 1
   • Other topical options:
     • Tazarotene: Effective but may cause irritation; best used with corticosteroids
     • Calcineurin inhibitors (tacrolimus, pimecrolimus): Particularly for facial and intertriginous areas; no risk of skin atrophy 1

2. Scalp Psoriasis

   • Medicated shampoos with coal tar, salicylic acid
   • Solutions/foams of corticosteroids or vitamin D analogs 1

Moderate-to-Severe Psoriasis

1. First-line: Biologic Therapy

   • IL-17 inhibitors (bimekizumab, ixekizumab, secukinumab, brodalumab): Higher efficacy for skin involvement than TNF inhibitors 1
   • IL-23 inhibitors (risankizumab, guselkumab): Excellent efficacy and safety profiles 1
   • TNF-α inhibitors (adalimumab): Particularly beneficial when psoriatic arthritis is present 1, 2
   • IL-12/23 inhibitor (ustekinumab): Effective for both skin and joint manifestations 1

2. Phototherapy Options

   • Narrowband UVB: First-line phototherapy option; can be combined with topicals 1
   • PUVA (psoralen plus UVA): For patients with inadequate response to UVB 1
   • Targeted phototherapy: 308-nm excimer laser for localized lesions and resistant areas 1

3. Oral Systemic Therapy

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

Special Considerations

Intertriginous and Genital Areas

• First-line: Topical calcineurin inhibitors or low-potency corticosteroids 1
• Avoid prolonged use of high-potency corticosteroids due to increased risk of atrophy 1

Pediatric Patients

• Use lower potency corticosteroids
• Biologic dosing is weight-based for children 1, 2

Psoriatic Arthritis

• Early treatment recommended to prevent joint damage
• NSAIDs for mild disease, DMARDs for moderate disease
• TNF inhibitors (adalimumab) for moderate-severe disease 1, 2

Safety Monitoring

• Topical corticosteroids: Monitor for skin atrophy, telangiectasia, and striae
• Methotrexate: Monitor for hepatotoxicity and bone marrow suppression
• Biologics: Monitor for infections and injection site reactions 1, 2
• Adalimumab warnings: Serious infections (including TB), malignancy risk (particularly lymphoma in children/adolescents) 2

Treatment Evaluation Timeline

• Topical therapy: Evaluate response after 4 weeks
• Limit potent corticosteroid use to 4 weeks to minimize risk of skin atrophy 1

Maintenance Therapy

• After achieving disease control, consider proactive maintenance therapy to prevent relapses
• Options include combination products or separate products (corticosteroid in morning, vitamin D analog in evening) 1

Common Pitfalls to Avoid

• Using high-potency corticosteroids on face, intertriginous areas, or genitalia for extended periods
• Exceeding recommended vitamin D analog dosage (risk of hypercalcemia)
• Inadequate monitoring of systemic therapies
• Failing to screen for TB before starting TNF inhibitors like adalimumab 1, 2