What is the management approach for chronic skin inflammation like psoriasis?

Management of Chronic Skin Inflammation: Psoriasis

The management of psoriasis requires a strategic approach targeting the underlying immune dysregulation with treatments selected based on disease severity, affected areas, and impact on quality of life. 1

Understanding Psoriasis

Psoriasis is a chronic inflammatory skin disease characterized by:

• Well-demarcated, red plaques with silvery scale
• Common locations: scalp, elbows, knees, presacral region
• Can affect any skin area including palms, soles, nails, and genitalia
• Immune-mediated condition involving T-cells, dendritic cells, and keratinocytes
• Associated with systemic inflammation and comorbidities including cardiovascular disease, metabolic syndrome, and psoriatic arthritis 1, 2

Disease Classification and Assessment

Severity Classification:

• Mild: <3% body surface area (BSA)
• Moderate: 3-10% BSA
• Severe: >10% BSA or involvement of high-impact areas 1

Special Considerations:

• Psoriasis can be severe regardless of BSA when:
  • Located on hands, feet, scalp, face, or genital areas
  • Causes significant emotional impact
  • Results in intractable pruritus 1

Assessment Tools:

• Psoriasis Area Severity Index (PASI): Measures extent and severity (0-72 scale)
• Evaluates redness, scaling, plaque thickness, and BSA
• Used primarily in clinical trials rather than routine practice 1

Treatment Algorithm

1. Mild Psoriasis (BSA <3%):

• First-line: Topical therapies
  • Topical corticosteroids
  • Vitamin D analogues (calcipotriol)
  • Calcineurin inhibitors (for sensitive areas)
  • Emollients 1, 3

2. Moderate Psoriasis (BSA 3-10%):

• First-line: Topical therapies + phototherapy
  • Narrowband UVB (more effective than broadband UVB)
  • 20-25 treatments, 2-3 times weekly 1
• Second-line: Consider adding systemic therapy if inadequate response

3. Severe Psoriasis (BSA >10% or high-impact areas):

• First-line: Systemic therapy ± topicals
  • Traditional systemics:
    • Methotrexate (immunosuppressive effect on lymphoid cells)
    • Cyclosporine (initial dose 2.5 mg/kg/day, maximum 4 mg/kg/day) 4
    • Acitretin (decreases keratinocyte hyperproliferation)
  • Small molecules:
    • PDE4 inhibitors (apremilast) 2
  • Biologics:
    • TNF inhibitors (infliximab, adalimumab, etanercept)
    • IL-12/23 inhibitors (ustekinumab)
    • IL-17 inhibitors (secukinumab, ixekizumab, brodalumab)
    • IL-23 inhibitors (guselkumab, tildrakizumab, risankizumab) 2, 5

Special Clinical Scenarios

Psoriatic Arthritis:

• Affects 30-33% of patients with psoriasis
• Screen all psoriasis patients for joint symptoms
• Early detection and aggressive treatment prevent joint damage
• Treatment options include NSAIDs (mild disease) and biologics (moderate-severe) 2

High-Impact Areas:

• Scalp: Medium-high potency topical steroids, vitamin D analogues
• Face/Intertriginous: Low potency steroids, calcineurin inhibitors
• Palmoplantar: High potency steroids under occlusion, systemic therapy for resistant cases
• Genital: Low potency steroids, calcineurin inhibitors 6

Monitoring and Follow-up

• Regular assessment of treatment response
• Monitor for treatment-specific adverse effects
• Screen for comorbidities (cardiovascular disease, metabolic syndrome)
• Consider treatment rotation for long-term management 1

Important Caveats

• Continuous treatment with cyclosporine beyond one year is not recommended 4
• After stopping cyclosporine, relapse occurs in approximately 6 weeks (50% of patients) to 16 weeks (75% of patients) 4
• Certain medications can trigger or worsen psoriasis (beta-blockers, lithium, antimalarials, interferons) 2
• Streptococcal infections can trigger guttate psoriasis 2
• Skin trauma (Koebner phenomenon) can initiate or exacerbate psoriasis 2

The management of psoriasis has evolved significantly with better understanding of its immunopathogenesis, allowing for targeted therapies that address the underlying inflammatory pathways and provide better disease control and quality of life for patients.