What is the diagnosis and treatment for psoriasis?

From the Guidelines

Psoriasis is a chronic autoimmune skin condition that should be treated with a stepped approach, starting with topical corticosteroids for mild cases, phototherapy or vitamin D analogs for moderate cases, and biologics or systemic medications for severe cases, as recommended by the most recent guidelines 1.

Diagnosis

Psoriasis is characterized by red, scaly patches that typically appear on the elbows, knees, scalp, and lower back. The diagnosis is primarily clinical, based on the appearance and distribution of the skin lesions.

Treatment

The treatment of psoriasis depends on the severity of the disease. For mild cases, topical corticosteroids like betamethasone or clobetasol applied twice daily are often effective 1. For moderate psoriasis, vitamin D analogs such as calcipotriene or phototherapy with UVB light 2-3 times weekly may be effective 1. Severe cases might require systemic medications including methotrexate (starting at 7.5-15mg weekly), biologics like adalimumab (40mg every other week) or secukinumab (300mg monthly), or oral retinoids such as acitretin (10-50mg daily) 1.

Lifestyle Modifications

Lifestyle modifications are also important in the management of psoriasis. Moisturizing regularly with thick creams, avoiding triggers like stress and alcohol, and minimizing skin trauma can help reduce symptoms 1.

Current Guidelines

The most recent guidelines for the management of psoriasis with biologics recommend a treatment approach that takes into account the severity of the disease, the presence of comorbidities, and the patient's preferences 1. The use of biologics such as adalimumab or secukinumab is recommended for patients with moderate to severe psoriasis who have failed to respond to topical therapies or phototherapy 1.

Quality of Life

The goal of treatment is to improve the patient's quality of life by reducing symptoms and improving skin clearance. Treatment should be tailored to meet individual patients' needs, taking into account their preferences, lifestyle, and comorbidities 1.

From the FDA Drug Label

Plaque Psoriasis (Ps) (1. 7): treatment of adult patients with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy, and when other systemic therapies are medically less appropriate. HUMIRA is a tumor necrosis factor (TNF) blocker indicated for: ... Plaque Psoriasis (Ps) (1.7): treatment of adult patients with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy, and when other systemic therapies are medically less appropriate. The diagnosis of psoriasis is not explicitly stated in the label, but the treatment for plaque psoriasis is indicated as adalimumab (HUMIRA) for adult patients with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy, and when other systemic therapies are medically less appropriate 2.

• The recommended dosage for plaque psoriasis is an 80 mg initial dose, followed by 40 mg every other week starting one week after initial dose 2.
• Adalimumab (HUMIRA) is a tumor necrosis factor (TNF) blocker 2 2.

From the Research

Diagnosis of Psoriasis

• Psoriasis is an immune-mediated disease with skin or joint manifestations, or both, and has a major impact on quality of life 3
• The diagnosis of psoriasis is typically based on clinical presentation, and the severity of the disease is assessed using measures such as the Psoriasis Area and Severity Index (PASI) 3

Treatment of Psoriasis

• Most psoriasis patients suffering from mild to moderate disease are treated with first-line topical treatments, including corticosteroids, vitamin D analogues, topical retinoids, and calcineurin inhibitors 4
• The combination of potent and superpotent corticosteroids with vitamin D analogues provides an improvement of psoriasis within 2 weeks, reaching a maximal improvement after 4 weeks in the majority of patients 4
• Systemic pharmacological treatments, including non-biological systemic agents, small molecules, and biologics, are used for moderate-to-severe psoriasis 3
• Biologic treatments, such as anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha, have been shown to be effective in achieving PASI 90 in people with moderate-to-severe psoriasis 3
• Infliximab, bimekizumab, ixekizumab, and risankizumab were found to be the most effective treatments for achieving PASI 90 in people with moderate-to-severe psoriasis 3
• Methotrexate is a classic antipsoriatic drug that is still very useful either as single-drug therapy or in combination with other systemic drugs, particularly as a rescue therapy or combined with biologics 5
• Narrow-band ultraviolet light B therapy and etanercept have been shown to be effective in combination for the treatment of moderate to severe plaque psoriasis 6

Treatment Options

• Topical treatments:
  • Corticosteroids
  • Vitamin D analogues
  • Topical retinoids
  • Calcineurin inhibitors
• Systemic treatments:
  • Non-biological systemic agents
  • Small molecules
  • Biologics (e.g. anti-IL17, anti-IL12/23, anti-IL23, anti-TNF alpha)
• Phototherapy:
  • Narrow-band ultraviolet light B therapy
• Combination therapy:
  • Etanercept plus narrow-band ultraviolet light B therapy
  • Methotrexate plus biologics