What are the treatment options for psoriasis?

Treatment Options for Psoriasis

For patients with psoriasis, treatment should be selected based on disease severity, with topical therapies for mild disease, and phototherapy or systemic therapies for moderate to severe disease. 1, 2

Disease Classification

• Psoriasis is classified as mild when affecting less than 5% body surface area (BSA) and moderate to severe when affecting 5% or more BSA 3, 1
• Patients with less than 5% BSA may still be classified as having moderate to severe disease if they have psoriasis in vulnerable areas (face, genitals, hands, feet, scalp, intertriginous areas) or significant quality of life impairment 3, 1
• Assessment should include both objective measures (BSA, PASI) and subjective measures of quality of life impact 2

Treatment Algorithm for Mild Psoriasis (< 5% BSA)

First-line Options:

• Topical corticosteroids - most effective for mild to moderate psoriasis, with ultrahigh potency (class 1) options like clobetasol propionate 0.05% and halobetasol propionate 0.05% 1, 2
• Vitamin D analogues (calcipotriene, calcitriol) - can be used for up to 52 weeks with good safety profile 1
• Combination therapy with vitamin D analogues and topical corticosteroids - more effective than either agent alone 1, 2

Second-line Options:

• Coal tar preparations - recommended for mild to moderate psoriasis 3
• Anthralin (dithranol) - effective but may cause skin irritation and staining 2
• Salicylic acid - useful as a keratolytic agent 2

Treatment Algorithm for Moderate to Severe Psoriasis (≥ 5% BSA or significant impact)

First-line Options:

• Phototherapy - narrowband UVB or PUVA (psoralen plus UVA) 3, 2
• Traditional systemic agents:
  • Methotrexate - effective for both skin and joint disease 3, 2
  • Cyclosporine - rapid acting but limited by nephrotoxicity 3, 2
  • Acitretin - oral retinoid, particularly effective for pustular forms 3, 2

Second-line Options:

• Biologic therapies:
  • TNF inhibitors (adalimumab, etanercept, infliximab) - effective for both skin and joint disease 4, 5
  • IL-12/23 inhibitors (ustekinumab) - target specific inflammatory pathways 5, 6
  • IL-17 inhibitors (secukinumab, ixekizumab, brodalumab) - highly effective for plaque psoriasis 5, 6
  • IL-23 inhibitors (guselkumab, tildrakizumab, risankizumab) - newest class with excellent efficacy 5, 6

Special Clinical Scenarios

Scalp Psoriasis:

• Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 1
• Medicated shampoos containing salicylic acid or coal tar 2

Facial and Intertriginous Psoriasis:

• Lower potency corticosteroids to avoid skin atrophy 1
• Calcineurin inhibitors (tacrolimus, pimecrolimus) as steroid-sparing agents 5

Psoriatic Arthritis:

• Methotrexate is recommended as first-line systemic therapy for patients with moderate to severe PsA 3
• If inadequate response after 12-16 weeks of methotrexate, consider adding or switching to a TNF inhibitor 3
• All TNF inhibitors (adalimumab, etanercept, infliximab) are equally reasonable choices 3, 4

Treatment Considerations and Monitoring

• Phototherapy requires specialized equipment and frequent treatments, but home UVB therapy is an attractive alternative for appropriate patients 3
• Systemic agents require careful monitoring for potential toxicities:
  • Methotrexate: liver function tests, complete blood count, renal function 3
  • Cyclosporine: blood pressure, renal function 3
  • Biologics: screening for tuberculosis and other infections before initiation 4

Common Pitfalls and Caveats

• Systemic corticosteroids should be avoided in psoriasis as they can cause disease flare during taper 2
• Combination of multiple systemic agents should be used with extreme caution due to additive toxicity 3
• Pregnancy considerations: Most systemic agents are contraindicated during pregnancy and require contraception 3
• Biologics carry risks of serious infections and potential malignancies, requiring careful patient selection and monitoring 4

Alternative and Complementary Approaches

• Stress reduction techniques and mindfulness meditation may improve outcomes in some patients with psoriasis 3
• For patients with celiac disease, a gluten-free diet may improve psoriasis symptoms 3
• Acupuncture may have modest benefits as adjunctive therapy based on patient interest 3