What are the management options for psoriasis?

Psoriasis Description and Management

The management of psoriasis should follow a stepwise approach based on disease severity, with topical therapies as first-line for mild disease, phototherapy for moderate disease, and systemic/biologic therapies for moderate-to-severe disease that has not responded to other treatments. 1

Disease Description

Psoriasis is a chronic inflammatory skin condition characterized by:

• Well-demarcated, erythematous plaques with silvery scale
• Predilection for extensor surfaces (elbows, knees), scalp, and intertriginous areas
• Variable presentations including plaque, guttate, pustular, and erythrodermic forms
• T-cell mediated pathophysiology with genetic and immunological components
• Associated comorbidities including psoriatic arthritis, cardiometabolic diseases, and depression 2

Assessment of Severity

• Body Surface Area (BSA): Recommended to assess severity and treatment response
  • Hand area (palm and fingers) represents approximately 1% BSA
  • Head/neck (10%), upper extremities (20%), trunk (30%), lower extremities/buttocks (40%) 3
• Mild: <3% BSA
• Moderate: 3-10% BSA
• Severe: >10% BSA or involvement of high-impact areas (face, genitals, hands/feet)

Treatment Algorithm

1. Topical Therapy (First-line for Mild Psoriasis)

• Corticosteroids:

  • Select potency based on treatment area:
    • High-potency (Class 1-2): For trunk and extremities
    • Medium-potency (Class 3-5): For thicker lesions
    • Low-potency (Class 6-7): For face, intertriginous areas, and genitalia 1
  • Limit high-potency use to 4 weeks to prevent skin atrophy 1

• Vitamin D Analogs (calcipotriene, calcitriol):

  • Can be used as monotherapy or in combination with corticosteroids
  • Maximum 100g weekly to avoid hypercalcemia
  • Combination with corticosteroids provides synergistic effects 1

• Calcineurin Inhibitors (tacrolimus, pimecrolimus):

  • Particularly effective for facial and intertriginous psoriasis
  • No risk of skin atrophy, but may cause burning sensation initially 1

• Other Topical Options:

  • Tazarotene (retinoid): Effective but may cause irritation
  • Coal tar preparations: Useful for scalp psoriasis
  • Salicylic acid: Helps remove scale 1, 4

2. Phototherapy (Second-line for Moderate Psoriasis)

• Narrowband UVB: First-line phototherapy option
• PUVA (psoralen plus UVA): For patients with inadequate response to UVB
• Targeted phototherapy (308-nm excimer laser): Effective for localized lesions 1

3. Systemic Therapy (For Moderate-to-Severe Psoriasis)

• Methotrexate:

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

• Cyclosporine:

  • Initial dose: 2.5 mg/kg/day divided twice daily
  • Provides rapid control but limited to short-term use (≤16 weeks)
  • Dose may be increased to maximum 4 mg/kg/day if no response after 4 weeks
  • Monitor for nephrotoxicity 1, 5

• Acitretin:

  • More effective for pustular variants
  • Absolutely contraindicated in women of childbearing potential due to teratogenicity 1

• PDE4 Inhibitors (apremilast):

  • Moderate efficacy but favorable safety profile 1

4. Biologic Therapy (For Moderate-to-Severe Psoriasis)

• TNF-α Inhibitors (adalimumab, etanercept, infliximab):

  • Particularly beneficial when psoriatic arthritis is present
  • Adalimumab: Subcutaneous injection, monitor for infections 1, 6

• IL-17 Inhibitors (secukinumab, ixekizumab):

  • Higher efficacy for skin involvement than TNF inhibitors 1

• IL-23 Inhibitors (guselkumab, risankizumab):

  • Excellent efficacy and safety profiles 1

• IL-12/23 Inhibitors (ustekinumab):

  • Effective for both skin and joint manifestations 1

Special Considerations

Intertriginous/Genital Psoriasis

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

Scalp Psoriasis

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

Stress Reduction

• Meditation techniques may improve outcomes in patients with mild to moderate psoriasis
• Guided mindfulness meditation can improve outcomes in patients qualifying for phototherapy
• Biofeedback and relaxation techniques may improve symptoms in some patients with mild psoriasis 3

Treatment Monitoring and Expectations

• Evaluate response after 4 weeks for topical therapy 1
• Psoriasis often requires long-term management; complete clearance may not be achievable for all patients
• Combination therapy can enhance efficacy and reduce side effects 1
• Proactive maintenance therapy after achieving control helps prevent relapses 1

Potential Pitfalls and Caveats

• Topical corticosteroids: Prolonged use can lead to skin atrophy, telangiectasia, and striae
• Cyclosporine: Limit treatment duration due to nephrotoxicity risk
• Methotrexate: Monitor for hepatotoxicity and bone marrow suppression
• Biologics: Screen for infections before initiating therapy; monitor for injection site reactions
• Rebound phenomenon: May occur after stopping treatment, particularly with cyclosporine 5

By following this structured approach to psoriasis management based on disease severity and location, clinicians can optimize treatment outcomes while minimizing adverse effects.