What are the treatment options for psoriasis?

Treatment Options for Psoriasis

Psoriasis treatment should be tailored based on disease severity, with topical therapies for mild disease and systemic or biologic therapies for moderate-to-severe disease, prioritizing medications that improve quality of life and reduce morbidity. 1

Disease Classification and Treatment Selection

Mild Psoriasis (Topical Therapy Candidates)

Patients with mild psoriasis who are candidates for topical therapy alone must meet ALL of the following criteria:

• Generally asymptomatic
• Minimal impact on quality of life
• Amenable and responsive to localized therapy
• Less than 5% body surface area for plaque psoriasis
• No incapacity and/or disability 1

Moderate to Severe Psoriasis (Systemic/Phototherapy Candidates)

Patients should meet at least ONE of the following criteria:

• Symptomatic (pain, bleeding, itching)
• More than minimal impact on quality of life
• Inadequate response to localized therapy
• Body surface area generally greater than 5% for plaque psoriasis
• Guttate, erythrodermic, or pustular psoriasis
• Psoriasis in vulnerable areas (face, genitals, hands/feet, nails, scalp, intertriginous areas)
• Varying degrees of incapacity and disability 1

First-Line Treatment Options

For Mild to Moderate Psoriasis

1. Topical Corticosteroids

   • Ultra-high potency (Class 1): Clobetasol propionate 0.05%, halobetasol propionate 0.05% 1
   • High potency (Class 2-3): Betamethasone dipropionate 0.05%, fluocinonide 0.05% 1
   • Medium potency (Class 4-5): Triamcinolone acetonide 0.1%, mometasone furoate 0.1% 1
   • Low potency (Class 6-7): For face and intertriginous areas 1
   • Efficacy: Rapid improvement within 2-4 weeks 2
   • Caution: Risk of skin atrophy, telangiectasia, and HPA axis suppression with prolonged use 3

2. Vitamin D Analogues

   • Calcipotriene/calcipotriol, calcitriol, tacalcitol, maxacalcitol 1
   • Can be used for up to 52 weeks 1
   • Particularly effective for scalp psoriasis when used as foam or gel formulations 1
   • Efficacy: Noticeable improvement in 6-8 weeks 2

3. Combination Therapy

   • Vitamin D analogues with topical corticosteroids (most effective approach) 1
   • Morning high-potency corticosteroid and evening vitamin D analogue 1
   • Weekday vitamin D analogues with weekend corticosteroids for maintenance 1

4. Other Topical Options

   • Tazarotene (topical retinoid): Effective in 1-2 weeks 2
   • Coal tar: Effective in 2-4 weeks 1
   • Anthralin: Short-contact therapy (up to 2 hours) for 8-12 weeks 1
   • Salicylic acid: Useful for thick, scaly plaques; can be combined with corticosteroids 1
   • Emollients: Help reduce itching, desquamation, and prevent relapse 1

For Moderate to Severe Psoriasis

1. Phototherapy

   • UVB/narrowband UVB
   • Oral PUVA (psoralen + UVA)
   • Bath PUVA
   • Can be combined with acitretin 1

2. Systemic Non-Biologic Therapies

   • Methotrexate 1
   • Cyclosporine (limited to less than 12 consecutive months due to cumulative toxicity) 1
   • Acitretin 1
   • Fumaric acid esters 1
   • Leflunomide 1

3. Biologic Therapies

   • TNF inhibitors (etanercept, adalimumab, infliximab) 1
   • IL-17 inhibitors
   • IL-23 inhibitors
   • IL-12/23 inhibitors

Special Considerations for Specific Psoriasis Types

Scalp Psoriasis

• Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 1
• Clobetasol propionate spray 0.05% has shown high efficacy 4

Facial Psoriasis

• Tacalcitol ointment or calcipotriene combined with hydrocortisone for 8 weeks 1
• Lower potency corticosteroids to avoid skin atrophy 1

Nail Psoriasis

• Topical vitamin D analogues combined with betamethasone dipropionate 1
• Limited efficacy due to poor penetration, particularly of the nail matrix 1

Palmoplantar Psoriasis

• Topical PUVA, acitretin 1
• Maxacalcitol ointment (not available in US) 1

Psoriatic Arthritis

• NSAIDs for mild disease 1
• DMARDs (sulfasalazine, leflunomide, methotrexate, cyclosporine) for moderate disease 1
• TNF inhibitors for severe disease or those who fail DMARD therapy 1

Treatment Strategies for Optimal Outcomes

Sequential and Rotational Therapy

• Start with more potent agents to achieve rapid control, then transition to maintenance therapy 2
• Intermittent corticosteroid therapy (weekend-only application) for chronic stage 2

Combination Approaches

• Topical corticosteroids plus vitamin D analogues (most effective combination) 1
• Avoid simultaneous use of salicylic acid with calcipotriene (acid pH inactivates calcipotriene) 1
• Topical agents can be added to systemic or biologic therapies for enhanced efficacy 4

Maintenance Therapy

• Intermittent topical steroid application can prolong remission 5
• Vitamin D analogues twice daily on weekdays with high-potency topical corticosteroids twice daily on weekends 1

Common Pitfalls and Caveats

• Systemic corticosteroids should generally be avoided in psoriasis as skin disease can flare during or after taper 1
• Vitamin D analogues should be applied after phototherapy to avoid inactivation by UVA and blocking UVB radiation 1
• Anthralin can stain skin and should be avoided on face and visible areas 1
• Aggressive immunosuppression should not follow extensive phototherapy (especially PUVA) due to increased risk of skin cancer 1
• Cyclosporine should be limited to less than 12 consecutive months due to cumulative toxicity 1