What are the treatment options for psoriasis?

Treatment Options for Psoriasis

The American Academy of Dermatology recommends a stepwise approach to psoriasis treatment, starting with topical therapies for mild disease, progressing to phototherapy, and then to systemic treatments for more severe cases. 1

Treatment Algorithm Based on Disease Severity

Mild Psoriasis (<3% Body Surface Area)

1. First-line: Topical Therapies

   • Topical Corticosteroids

     • Class selection based on location:
       • Class 1 (Ultrahigh-potency): Clobetasol propionate, halobetasol propionate - for thick plaques 1, 2
       • Class 2-5 (High to moderate potency): Betamethasone dipropionate, triamcinolone acetonide - for body 1
       • Class 6-7 (Low potency): Hydrocortisone, desonide - for face, intertriginous areas 1

   • Vitamin D Analogs

     • Can be used as monotherapy or combined with corticosteroids
     • Maximum 100g weekly to avoid hypercalcemia 1

   • Calcineurin Inhibitors

     • Tacrolimus or pimecrolimus for sensitive areas (face, intertriginous, genital)
     • No risk of skin atrophy but may cause initial burning sensation 1

   • Tazarotene

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

Moderate to Severe Psoriasis (>3% Body Surface Area)

1. First-line: Phototherapy

   • Narrowband UVB is the preferred first-line phototherapy option
   • Can be combined with topical treatments
   • Targeted phototherapy (308-nm excimer laser) for localized lesions and resistant areas 1

2. Second-line: Traditional Systemic Agents

   • Methotrexate

     • Starting dose: 10-15 mg weekly with appropriate monitoring 1

   • Cyclosporine

     • Dose: 2.5-5 mg/kg/day
     • Provides rapid control but limited to short-term use due to nephrotoxicity 1

   • Acitretin

     • Less effective as monotherapy
     • More effective for pustular psoriasis variants
     • Contraindicated in women of childbearing potential (teratogenic) 1

3. Third-line: Newer Oral Agents

   • PDE4 inhibitors (apremilast)

     • Moderate efficacy but favorable safety profile 1

   • JAK inhibitors

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

4. Fourth-line: Biologics

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

     • Effective for both skin and joint manifestations 1, 3
     • Adalimumab dosing: 80 mg initial dose, followed by 40 mg every other week 3

   • IL-17 inhibitors

     • Highly effective for skin manifestations 1

   • IL-23 inhibitors

     • Highly effective with infrequent dosing 1

   • IL-12/23 inhibitor

     • Effective for both skin and joint disease 1

Special Considerations for Specific Areas

Scalp Psoriasis

• First-line: Topical corticosteroids 1
• Alternative: Targeted phototherapy with excimer laser 1
• For resistant cases: Combination therapy with vitamin D analogs 1

Intertriginous Areas

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

Genital Psoriasis

• Requires special attention due to significant psychological impact 1
• Low-potency corticosteroids or calcineurin inhibitors 1

Combination and Sequential Therapy

• Combination Therapy

  • Topical corticosteroids + vitamin D analogs - enhances efficacy while reducing side effects 1
  • Topical therapy + phototherapy - improves response rates 1
  • Clobetasol propionate spray has shown efficacy as add-on therapy to biologics for residual plaques 4

• Treatment Evaluation Timeline

  • Evaluate response after 4 weeks for topical therapy 1
  • For biologics like adalimumab, significant improvement should be seen within 4-8 weeks 3

Important Safety Considerations

• Corticosteroids

  • Monitor for skin atrophy, telangiectasia, and striae 1, 5
  • Limit high-potency use to 2-4 weeks 1, 5

• Biologics (e.g., Adalimumab)

  • Increased risk of serious infections including TB, bacterial sepsis, and invasive fungal infections 3
  • Screen for latent TB before initiating therapy 3
  • Monitor for malignancy risk, especially lymphoma in younger patients 3
  • Risk of anaphylaxis or serious hypersensitivity reactions 3

• Methotrexate

  • Monitor for hepatotoxicity and bone marrow suppression 1
  • Contraindicated in pregnancy 1

• Cyclosporine

  • Monitor renal function and blood pressure 1
  • Limited to short-term use (typically 1 year maximum) 1

Treatment Selection Pitfalls

• Skipping traditional systemic therapies without specific contraindications is not recommended 1
• Undertreatment of psoriasis can lead to poor quality of life and disease progression 1, 2
• Overuse of high-potency corticosteroids can lead to tachyphylaxis and adverse effects 1
• Failing to address comorbidities like psoriatic arthritis can lead to joint damage 1

Clobetasol propionate 0.05% spray has demonstrated significant improvement in quality of life measures and is effective for plaque psoriasis, with studies showing 75% of patients achieving clear or almost clear status after 4 weeks of treatment 2, 6.