What are the treatment options for psoriasis?

Treatment Options for Psoriasis

The first-line treatment for psoriasis should be topical corticosteroids for mild to moderate disease, with progression to systemic therapies such as methotrexate or biologics like adalimumab for moderate to severe disease. 1

Treatment Algorithm Based on Disease Severity

Mild to Moderate Psoriasis (<3% BSA)

• First-line therapy:

  • Topical corticosteroids (strength of recommendation: A) 1
    • 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
  • Coal tar preparations (strength of recommendation: A) 1

• Alternative/adjunctive therapies:

  • Topical calcineurin inhibitors (tacrolimus) for intertriginous areas 1
  • Regular use of emollients 1

Moderate to Severe Psoriasis (>3% BSA or high-impact areas)

• First-line systemic therapies:

  • Methotrexate (starting dose 10-15 mg weekly) 1
  • Cyclosporine (2.5-5 mg/kg/day) for rapid control but limited to short-term use due to nephrotoxicity 1

• Biologic therapies for moderate to severe disease:

  • Adalimumab (HUMIRA) - FDA-approved for moderate to severe plaque psoriasis 2
    • Dosing: 80 mg initial dose, followed by 40 mg every other week starting one week after initial dose 2

• Phototherapy options:

  • UVB phototherapy alone or in combination with coal tar (Goeckerman therapy) 1

Special Considerations for Specific Body Areas

Scalp Psoriasis

• Topical corticosteroids of appropriate potency 1
• Consider higher potency formulations for thick plaques

Intertriginous/Genital Areas

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

Pediatric Patients

• Use lower potency corticosteroids, especially in children with ≥4 psoriasis-associated features 1
• Children 0-6 years are particularly vulnerable to HPA suppression with high-potency corticosteroids 1
• For moderate to severe disease in children, adalimumab is approved for specific indications with weight-based dosing 2

Monitoring and Assessment

• Evaluate response after 4 weeks for topical therapy 1
• Disease severity classification:
  • Mild: <3% BSA
  • Moderate: 3-10% BSA
  • Severe: >10% BSA or involvement of high-impact areas 1
• Regular monitoring for adverse effects:
  • Topical corticosteroids: skin atrophy, telangiectasia, striae
  • Methotrexate: hepatotoxicity, bone marrow suppression
  • Biologics: infections, injection site reactions 1

Important Considerations and Pitfalls

• Avoid prolonged use of high-potency corticosteroids, especially on the face, intertriginous areas, and in children
• Do not start biologics like adalimumab during active infections; screen for tuberculosis before initiating therapy 2
• Be aware of increased risk of serious infections and malignancies with TNF blockers like adalimumab 2
• Consider rotation of therapies for long-term management to minimize cumulative toxicity of any single agent
• Recognize that psoriasis treatment should address both skin manifestations and potential comorbidities such as psoriatic arthritis

The treatment approach should follow a stepwise progression based on disease severity, location, and response to previous therapies, with careful attention to monitoring for adverse effects and adjusting therapy accordingly.