What are the treatment options for managing psoriasis?

Management of Psoriasis

For effective psoriasis management, a combination of potent corticosteroids with vitamin D analogs is recommended as first-line treatment for mild to moderate psoriasis, with biologics reserved for moderate to severe cases. 1

Topical Therapy - First Line for Mild to Moderate Psoriasis

Corticosteroids

• Selection based on location and severity:

  • Class 1 (Ultra-high potency): Clobetasol propionate 0.05%, halobetasol propionate 0.05%
    • For thick, chronic plaques 2, 1
  • Class 2-5 (High to moderate potency): Betamethasone dipropionate, triamcinolone acetonide
    • For trunk and extremities 1
  • Class 6-7 (Low potency): Hydrocortisone, desonide
    • For face, intertriginous areas, and genitalia 1

• Application guidelines:

  • Limit high-potency corticosteroids to 4 weeks to prevent skin atrophy 1
  • For maintenance, consider weekend-only application 3

Vitamin D Analogs

• Calcipotriene/calcitriol
• Maximum 100g weekly to avoid hypercalcemia 1
• Excellent for combination therapy with corticosteroids

Combination Approaches

• Morning corticosteroid + evening vitamin D analog 1
• Weekday/weekend regimen (vitamin D analog on weekdays, corticosteroid on weekends) shows excellent efficacy 3

Other Topical Options

• Calcineurin inhibitors (tacrolimus, pimecrolimus)
  • First-line for facial and intertriginous areas
  • No risk of skin atrophy 1
• Tazarotene
  • Effective but may cause irritation
  • Best used with corticosteroids 1

Phototherapy - For Moderate Psoriasis

• Narrowband UVB: First-line phototherapy option 1
• PUVA (psoralen plus UVA): For cases where UVB is inadequate 1
• Targeted phototherapy (308-nm excimer laser): For localized lesions 1

Systemic Therapy - For Moderate to Severe Psoriasis

Traditional Systemics

• Methotrexate: 10-15 mg weekly
  • Requires CBC, liver function, and renal function monitoring 1
• Cyclosporine: Rapid control but limited to short-term use due to nephrotoxicity 1
• Acitretin: More effective for pustular variants
  • Contraindicated in women of childbearing potential 1

Biologics

• TNF-α inhibitors (e.g., adalimumab)
  • Indicated for moderate to severe plaque psoriasis 4
  • Particularly useful when psoriatic arthritis is present 1
  • Warning: Risk of serious infections and malignancy 4
• IL-17 inhibitors
  • Higher efficacy for skin involvement than TNF inhibitors 1
• IL-23 inhibitors
  • Excellent efficacy and safety profiles 1
• IL-12/23 inhibitors
  • Effective for both skin and joint manifestations 1

Oral Small Molecules

• JAK inhibitors: Oral agents blocking multiple cytokine pathways 1
• PDE4 inhibitors (apremilast): Moderate efficacy with favorable safety profile 1

Special Considerations

Scalp Psoriasis

• Medicated shampoos containing coal tar, salicylic acid
• Solutions or foams of corticosteroids or vitamin D analogs 1
• Clobetasol propionate 0.05% spray shows significant improvement in quality of life for scalp psoriasis 5

Intertriginous Areas

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

Vehicle Considerations

• Patient preference significantly impacts adherence
• Clobetasol propionate is available in multiple formulations (ointment, cream, spray, foam, lotion, shampoo)
• Efficacy rates are similar across different vehicles in clinical trials 6, 7
• For patients who find ointments messy, newer formulations (spray, foam) may improve adherence 7

Adjunctive Therapies

• Stress reduction techniques may improve symptoms in some patients with mild psoriasis 2
• Mindfulness meditation can improve outcomes in patients with moderate psoriasis 2
• Oral curcumin supplementation may benefit as adjunctive therapy 2
• Gluten-free diet only recommended for patients diagnosed with celiac disease 2

Treatment Algorithm

1. Mild localized psoriasis:

   • Start with topical corticosteroid + vitamin D analog combination
   • Adjust corticosteroid potency based on location
   • Evaluate response after 4 weeks

2. Moderate psoriasis or inadequate response to topicals:

   • Add phototherapy (narrowband UVB)
   • Consider adding systemic therapy if inadequate response

3. Severe psoriasis:

   • Start biologics (TNF-α, IL-17, or IL-23 inhibitors)
   • Can combine with topical therapy for resistant plaques 8

4. Psoriasis with arthritis:

   • Prioritize TNF-α inhibitors or IL-12/23 inhibitors

Monitoring

• Evaluate topical therapy response after 4 weeks 1
• Monitor for adverse effects:
  • Corticosteroids: skin atrophy, telangiectasia, striae
  • Biologics: infections, injection site reactions
  • Methotrexate: hepatotoxicity, bone marrow suppression 1