What are the management options for psoriasis?

Management Options for Psoriasis

The management of psoriasis should follow a stepwise approach based on disease severity, with topical therapies for mild disease, phototherapy for moderate disease, and systemic or biologic therapies for severe or refractory cases. 1

Disease Severity Assessment

• Assess disease severity using Body Surface Area (BSA):
  • Mild: <3% BSA
  • Moderate: 3-10% BSA
  • Severe: >10% BSA or involvement of high-impact areas 1

Treatment Algorithm

First-Line: Topical Therapies (Mild Psoriasis)

• Topical corticosteroids:

  • First-line treatment for mild disease 1
  • Select potency based on treatment area:
    • Class 1 (Ultrahigh-potency): Clobetasol propionate, Halobetasol propionate
    • Class 2-5 (High to moderate potency): Betamethasone dipropionate, Triamcinolone acetonide
    • Class 6-7 (Low potency): Hydrocortisone, Desonide
  • Limit high-potency use to 4 weeks to prevent skin atrophy 1

• Vitamin D analogs:

  • Can be used as monotherapy or in combination with corticosteroids
  • Maximum 100g weekly to avoid hypercalcemia 1
  • Combination with corticosteroids enhances efficacy and reduces side effects

• Special locations:

  • Facial/intertriginous areas: Topical calcineurin inhibitors or low-potency corticosteroids 1
  • Scalp: Medicated shampoos containing coal tar, salicylic acid, or solutions/foams of corticosteroids 1

Second-Line: Phototherapy (Moderate Psoriasis)

• Narrowband UVB:

  • First-line phototherapy option 1
  • Can be combined with topical treatments
  • Home UV phototherapy is an alternative for appropriate patients

• PUVA (Psoralens plus UVA):

  • Consider if narrowband UVB is ineffective
  • Probably the least toxic of all systemic agents 2
  • Starting dose should be 70% of minimum phototoxic dose with successive doses increased by 40% 2

• Targeted phototherapy:

  • 308-nm excimer laser for localized lesions and resistant areas 1

Third-Line: Systemic Therapies (Moderate to Severe Psoriasis)

Indications for systemic treatment 2:

• Failure of adequate trial of topical treatment
• Repeated hospital admissions for topical treatment
• Extensive chronic plaque psoriasis in elderly or infirm people
• Generalized pustular or erythrodermic psoriasis
• Severe psoriatic arthropathy

Traditional Systemics:

• Methotrexate:

  • Starting dose: 10-15 mg weekly 1
  • Especially useful for acute generalized pustular psoriasis, erythroderma, and psoriatic arthritis 2
  • Monitoring: CBC, liver function, renal function
  • Contraindications: Pregnancy, breastfeeding, wish to father children, significant hepatic damage, blood disorders 2

• Cyclosporine:

  • Provides rapid control of severe psoriasis
  • Limited to short-term use due to nephrotoxicity 1
  • Monitor blood pressure and serum creatinine 2

• Acitretin (oral retinoid):

  • Less effective as monotherapy but more effective for pustular variants
  • Absolutely contraindicated in women of childbearing potential due to teratogenicity 1
  • Response time: 6 weeks 2

Newer Oral Agents:

• JAK inhibitors:

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

• PDE4 inhibitors (e.g., apremilast):

  • Moderate efficacy but favorable safety profile 1

Fourth-Line: Biologics (Severe or Refractory Psoriasis)

• IL-17 inhibitors:

  • Higher efficacy for skin involvement than TNF inhibitors 1
  • Monitor for inflammatory bowel disease exacerbations

• IL-23 inhibitors:

  • Excellent efficacy and safety profiles 1

• TNF-α inhibitors (e.g., adalimumab):

  • Recommended particularly when psoriatic arthritis is present 1
  • Evaluate for tuberculosis prior to initiating treatment

• IL-12/23 inhibitors:

  • Effective for both skin and joint manifestations 1
  • Strong recommendation for skin and nail disease

Special Considerations

Combination and Rotational Therapy

• Consider combination therapy to enhance efficacy and reduce side effects 1
• Rotational therapy (switching between different treatments every 1-2 years) may minimize cumulative toxicity of individual treatments 3

Monitoring and Safety

• Evaluate response:

  • Topical therapy: After 4 weeks
  • Systemic therapy: Based on specific agent (2-6 weeks) 2, 1

• Common adverse effects to monitor:

  • Corticosteroids: Skin atrophy, telangiectasia, striae
  • Methotrexate: Hepatotoxicity, bone marrow suppression
  • Biologics: Infections, injection site reactions
  • PUVA: Skin cancer risk with long-term use 2

Precautions with Biologics

• Screen for tuberculosis prior to initiating treatment 4
• Monitor for signs of infection during treatment 4
• Avoid live vaccines in patients treated with biologics 4
• Monitor for inflammatory bowel disease, especially with IL-17 inhibitors 4

Practical Approach

1. For mild psoriasis (<3% BSA):

   • Start with topical corticosteroids appropriate for the location
   • Add vitamin D analogs for enhanced efficacy
   • Consider calcineurin inhibitors for sensitive areas

2. For moderate psoriasis (3-10% BSA):

   • Begin with phototherapy (narrowband UVB)
   • Consider adding topical agents for resistant areas
   • If inadequate response, consider systemic agents

3. For severe psoriasis (>10% BSA):

   • Start with traditional systemic agents (methotrexate or cyclosporine)
   • For inadequate response or contraindications, consider biologics
   • Select biologic based on comorbidities (e.g., TNF inhibitors for psoriatic arthritis)

By following this evidence-based, stepwise approach to psoriasis management, clinicians can effectively control disease while minimizing adverse effects and improving patients' quality of life.