What are the treatment options for psoriasis?

Treatment Options for Psoriasis

For psoriasis treatment, a combination of topical corticosteroids with vitamin D analogs is recommended as first-line therapy for mild disease, while biologics (particularly IL-17 and IL-23 inhibitors) are recommended for moderate-to-severe disease. 1

Assessment for Treatment Selection

Treatment selection depends on disease severity:

• Mild psoriasis (candidates for topical therapy alone):

  • Asymptomatic
  • Minimal impact on quality of life
  • Less than 5% body surface area affected
  • No incapacity/disability 2

• Moderate-to-severe psoriasis (candidates for systemic/phototherapy):

  • Symptomatic (pain, bleeding, itching)
  • More than minimal impact on quality of life
  • Body surface area >5%
  • Inadequate response to topical therapy
  • Guttate, erythrodermic, or pustular variants
  • Psoriasis in vulnerable areas (face, genitals, hands/feet, nails, scalp, intertriginous)
  • Incapacity/disability 2, 1

Topical Therapy Options

First-line for Mild Psoriasis

• Combination of potent corticosteroid with vitamin D analog:
  • Provides synergistic effects
  • Reduces corticosteroid-related side effects 1
  • Apply corticosteroid in morning, vitamin D analog in evening 3

Corticosteroid Selection

• Potency should match treatment area:
  • High-potency: trunk and extremities
  • Low-potency: face, intertriginous areas, genitalia 1
  • Potency classes:
    • Class 1 (Ultrahigh): Clobetasol propionate, Halobetasol propionate
    • Class 2-5 (High-moderate): Betamethasone dipropionate, Triamcinolone acetonide
    • Class 6-7 (Low): Hydrocortisone, Desonide 1

Other Topical Options

• Calcineurin inhibitors (tacrolimus, pimecrolimus):

  • Particularly effective for facial and intertriginous psoriasis
  • No risk of skin atrophy 1, 4

• Tazarotene:

  • Effective but may cause irritation
  • Best used in combination with corticosteroids 1, 4

• Scalp psoriasis:

  • Medicated shampoos with coal tar, salicylic acid
  • Solutions/foams of corticosteroids or vitamin D analogs 1, 4

Phototherapy Options

• Narrowband UVB:

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

• PUVA (psoralen plus UVA):

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

• Targeted phototherapy (308-nm excimer laser):

  • Effective for localized lesions and resistant areas 1

Systemic Therapy Options

Traditional Systemics

• Methotrexate:

  • Starting dose: 10-15 mg weekly
  • Requires monitoring of CBC, liver function, and renal function 1

• Cyclosporine:

  • Rapid control of severe psoriasis
  • 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

Biologic Therapy

• 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):

  • Recommended for moderate-to-severe psoriasis
  • Particularly beneficial when psoriatic arthritis is present
  • Adalimumab dosing: 80 mg initial dose, followed by 40 mg every other week 1, 5
  • Warning: Increased risk of serious infections and malignancy 5

• IL-12/23 inhibitors:

  • Effective for both skin and joint manifestations 1

Oral Small Molecules

• JAK inhibitors:

  • Block multiple cytokine pathways
  • Strong recommendation for moderate-to-severe psoriasis 1

• PDE4 inhibitors (apremilast):

  • Moderate efficacy but favorable safety profile 1

Special Considerations

Intertriginous/Genital Psoriasis

• First-line: Topical calcineurin inhibitors or low-potency corticosteroids 1, 4
• Avoid prolonged use of high-potency corticosteroids (risk of atrophy) 1

Pediatric Patients

• Use lower potency corticosteroids 1
• Special attention for children with ≥4 psoriasis-associated features 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 and Maintenance

• Evaluate response after 4 weeks for topical therapy 1
• Limit potent corticosteroid use to 4 weeks to minimize skin atrophy risk 1
• Consider proactive maintenance therapy after achieving control:
  • Use combination products or separate products
  • Apply corticosteroid in morning, vitamin D analog in evening 1

Common Pitfalls to Avoid

1. Overuse of potent corticosteroids:

   • Can lead to skin atrophy, telangiectasia, and striae
   • Limit use to 4 weeks, especially on face/intertriginous areas 1

2. Inadequate monitoring:

   • Regular monitoring needed for adverse effects
   • Particularly important with methotrexate (hepatotoxicity, bone marrow suppression) and biologics (infections) 1

3. Undertreatment of moderate-to-severe disease:

   • Delay in escalating to systemic therapy can lead to disease progression
   • Early treatment with appropriate agents prevents joint damage in psoriatic arthritis 1

4. Neglecting special sites:

   • Face, scalp, genitals, and intertriginous areas require specific approaches
   • These areas significantly impact quality of life 1, 4