What are the treatment options for psoriasis?

Treatment Options for Psoriasis

The most effective treatment approach for psoriasis follows a stepwise algorithm based on disease severity, with topical corticosteroids as first-line for mild disease, phototherapy or traditional systemic agents for moderate disease, and biologics for severe or refractory cases. 1

Disease Classification and Assessment

• Disease severity classification:

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

• Assessment tools:

  • BSA calculation: hand area represents approximately 1% BSA
  • Distribution: head/neck (10%), upper extremities (20%), trunk (30%), lower extremities/buttocks (40%) 1

Treatment Algorithm by Disease Severity

1. Mild Psoriasis (<3% BSA)

• First-line: Topical therapies

  • Topical corticosteroids - classified by potency:

    • 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 1

  • Vitamin D analogs: Used as monotherapy or in combination with corticosteroids (maximum 100g weekly to avoid hypercalcemia) 1

  • Retinoids: Tazarotene (effective but may cause irritation, best used with corticosteroids) 1

  • Calcineurin inhibitors: Tacrolimus or pimecrolimus for sensitive areas (no risk of skin atrophy) 1

2. Moderate Psoriasis (3-10% BSA)

• First-line: Phototherapy or traditional systemic agents 1

  • Phototherapy options:

    • Narrowband UVB (first-line phototherapy)
    • PUVA (psoralen plus UVA)
    • Targeted phototherapy with 308-nm excimer laser for localized lesions 1

  • Traditional systemic agents:

    • Methotrexate: Starting dose 10-15 mg weekly with appropriate monitoring 1
    • Cyclosporine: 2.5-5 mg/kg/day for rapid control (limited to short-term use due to nephrotoxicity) 1
    • Acitretin: Less effective as monotherapy, better for pustular variants (contraindicated in women of childbearing potential) 1

3. Severe Psoriasis (>10% BSA)

• First-line: Traditional systemic agents or biologics 1, 2

  • Biologics (by mechanism):

    • TNF-α inhibitors: Etanercept, adalimumab, certolizumab, infliximab
    • IL-17 inhibitors: Secukinumab, ixekizumab, brodalumab
    • IL-23 inhibitors: Guselkumab, tildrakizumab, risankizumab
    • IL-12/23 inhibitor: Ustekinumab 2

  • Oral agents:

    • PDE4 inhibitors (apremilast): Moderate efficacy but favorable safety profile 1
    • JAK inhibitors: Block multiple cytokine pathways 1

Special Considerations

Psoriatic Arthritis

• For mild disease: NSAIDs
• For moderate disease: DMARDs
• For moderate-severe disease: TNF inhibitors 1

Special Anatomical Areas

• Scalp psoriasis: Topical corticosteroids (first-line), targeted phototherapy with excimer laser 1
• Intertriginous areas: Topical calcineurin inhibitors or low-potency corticosteroids 1
• Genital psoriasis: Requires special attention due to psychological impact 1

Pediatric Patients

• Use lower potency corticosteroids, particularly in children with ≥4 psoriasis-associated features 1

Monitoring and Adverse Effects

• Topical corticosteroids: Monitor for skin atrophy, telangiectasia, striae, and HPA axis suppression with prolonged use 3

  • Clobetasol propionate may cause burning/stinging sensation (most common), scalp pustules, folliculitis, and rarely skin atrophy 3
  • Limit treatment courses to 2-4 weeks to minimize adverse effects 3, 4

• Systemic agents: Regular monitoring for specific toxicities

  • Methotrexate: Hepatotoxicity and bone marrow suppression
  • Cyclosporine: Nephrotoxicity
  • Biologics: Infections and injection site reactions 1

Treatment Evaluation

• Evaluate response after 4 weeks for topical therapy
• Consider combination, rotational, or sequential therapy to enhance efficacy and reduce side effects 1, 5
• For chronic management, consider intermittent corticosteroid therapy (every-other-day or weekend-only application) 5

Practical Tips

• Adherence to treatment is a critical determinant of success, often more important than small differences in drug delivery 4
• Newer formulations of topical corticosteroids (foams, sprays, lotions) may improve adherence compared to traditional ointments 4, 6
• Combination therapy (e.g., corticosteroids with vitamin D analogs) often provides better results than monotherapy 5