What are the treatment options for psoriasis?

Treatment Options for Psoriasis

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

Disease Classification and Initial Assessment

• Disease severity classification:

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

• Special considerations:

  • Location of lesions (scalp, intertriginous areas, genitals)
  • Presence of psoriatic arthritis
  • Impact on quality of life

Treatment Algorithm by Disease Severity

Mild Psoriasis (<3% BSA)

1. First-line: Topical Corticosteroids

   • Mid to high-potency (Class 2-5) for body treatment
   • Duration: 2-4 weeks with gradual tapering
   • Efficacy: 41-92% improvement depending on potency 1
   • For scalp: Class 1 (ultrahigh-potency) such as clobetasol propionate
   • For intertriginous/genital areas: Low-potency corticosteroids or calcineurin inhibitors

2. Second-line: Vitamin D Analogues

   • Calcipotriene, calcitriol, tacalcitol
   • Most effective when combined with corticosteroids
   • 14-27% of patients achieve clear/almost clear skin as monotherapy 1

3. Alternative options:

   • Coal tar preparations (particularly for thick, scaly plaques)
   • Duration: 8-16 weeks 1

Moderate to Severe Psoriasis (≥3% BSA)

1. First-line: Phototherapy

   • Narrowband UVB
   • PUVA (psoralen plus UVA)
   • Evaluate response after 4 weeks 1

2. Second-line: Systemic Conventional Agents

   • Methotrexate:

     • Starting dose: 10-15 mg weekly
     • Monitor for hepatotoxicity and bone marrow suppression 1

   • Cyclosporine:

     • Dose: 2.5-5 mg/kg/day
     • Provides rapid control but limited to short-term use due to nephrotoxicity
     • Maximum duration: 12 consecutive months 1

3. Third-line: Biologics

   • TNF inhibitors (adalimumab, etanercept, infliximab):

     • Indicated for moderate to severe plaque psoriasis 2
     • Adalimumab dosing: 80 mg initial dose, followed by 40 mg every other week 2
     • Monitor for serious infections and malignancy risk 2

   • IL-17 inhibitors (secukinumab, ixekizumab)

   • IL-12/23 inhibitors (ustekinumab)

   • IL-23 inhibitors (guselkumab, risankizumab)

Special Situations

Psoriatic Arthritis

• First-line for mild peripheral arthritis: NSAIDs 3
• For moderate to severe peripheral arthritis: DMARDs (sulfasalazine, leflunomide, methotrexate) 3
• For inadequate response to DMARDs: TNF inhibitors 3
• For axial disease: NSAIDs, physical therapy; TNF inhibitors if inadequate response 3

Nail Psoriasis

• Consider retinoids, oral PUVA, cyclosporine, or TNF inhibitors 3

Scalp Psoriasis

• Ultrahigh-potency topical corticosteroids (Class 1) 1
• Consider solutions or foams for better penetration

Intertriginous/Genital Psoriasis

• Low-potency corticosteroids or topical calcineurin inhibitors 1
• Avoid high-potency corticosteroids in these sensitive areas

Treatment Evaluation and Monitoring

• Evaluate response to topical therapy after 4 weeks 1
• For biologics like adalimumab, monitor for:
  • Serious infections (including tuberculosis)
  • Malignancy
  • Hypersensitivity reactions 2
• For methotrexate, monitor for hepatotoxicity and bone marrow suppression
• For cyclosporine, monitor renal function

Common Pitfalls and Caveats

1. Corticosteroid-related issues:

   • Avoid prolonged use of high-potency corticosteroids to prevent skin atrophy, telangiectasia, and striae
   • Use lower potency corticosteroids in children and sensitive areas

2. Phototherapy limitations:

   • Increased risk of skin cancer with extensive PUVA therapy
   • Avoid aggressive immunosuppression following extensive phototherapy 1

3. Biologic therapy considerations:

   • Screen for tuberculosis before initiating TNF inhibitors
   • Discontinue if serious infection develops 2
   • Higher cost compared to conventional therapies

4. Cyclosporine limitations:

   • Should be limited to less than 12 consecutive months due to cumulative toxicity 1

By following this evidence-based treatment algorithm and considering the specific characteristics of each patient's disease, most cases of psoriasis can be effectively managed with significant improvements in quality of life.