What are the treatment options for psoriasis?

Treatment of Psoriasis

The most effective treatment approach for psoriasis involves a stepwise algorithm based on disease severity, with topical corticosteroids and vitamin D analogs as first-line therapy for mild disease, and systemic or biologic agents for moderate-to-severe disease. 1, 2

Disease Classification and Treatment Selection

• Psoriasis severity is categorized as mild (<3% body surface area [BSA]), moderate (3-10% BSA), or severe (≥10% BSA), with treatment options tailored accordingly 1, 3
• Patients with symptomatic psoriasis (pain, bleeding, itching) should be considered for systemic or phototherapy even if BSA involvement is limited 2
• Patients with moderate-to-severe psoriasis should meet at least one of the following criteria: symptomatic disease, significant impact on quality of life, inadequate response to localized therapy, or varying degrees of disability 2, 3

First-Line Treatment for Mild Psoriasis

• Topical corticosteroids are the cornerstone of treatment for mild psoriasis, with ultrahigh potency (class 1) agents like clobetasol propionate 0.05% and halobetasol propionate 0.05% recommended for plaque psoriasis 1, 2, 4
• Vitamin D analogues (calcipotriene, calcitriol) can be used for up to 52 weeks and are particularly effective for scalp psoriasis 2, 5
• Combination therapy with vitamin D analogues and topical corticosteroids is more effective than either agent alone 1, 2, 6
• Coal tar preparations are recommended for mild to moderate psoriasis (strength of recommendation: A) 1
• Other topical options include anthralin, tazarotene, and salicylic acid, which can be used in specific clinical scenarios 2, 6, 5

Treatment for Moderate-to-Severe Psoriasis

• Phototherapy is recommended as first-line treatment for moderate-to-severe psoriasis, including narrowband UVB and PUVA 3
• Traditional systemic agents for moderate-to-severe psoriasis include methotrexate, cyclosporine, and acitretin 1, 3
• Biologic therapies (TNF inhibitors, IL-17 inhibitors, IL-23 inhibitors) are effective options for moderate-to-severe disease 2, 3
• The addition of topical therapies to systemic treatments can enhance efficacy:
  • Class 1 topical corticosteroids combined with etanercept is recommended (strength of recommendation: A) 1
  • Calcipotriene/betamethasone combined with adalimumab accelerates clearance (strength of recommendation: B) 1
  • Topical calcipotriene added to methotrexate is recommended for moderate-to-severe psoriasis (strength of recommendation: A) 1

Special Considerations for Specific Psoriasis Types

• For scalp psoriasis, calcipotriene foam or calcipotriene plus betamethasone dipropionate gel can be used for 4-12 weeks 2, 5
• For facial and intertriginous psoriasis, lower potency corticosteroids or calcineurin inhibitors (tacrolimus, pimecrolimus) are recommended to avoid skin atrophy 2, 5
• For nail psoriasis, topical vitamin D analogues combined with betamethasone dipropionate can be used, though efficacy may be limited due to poor penetration 2, 5

Safety Considerations and Monitoring

• Topical corticosteroids can cause adverse effects including skin atrophy, striae, telangiectasia, and hypothalamic-pituitary-adrenal axis suppression with prolonged use 4, 7
• Common adverse reactions with clobetasol propionate include burning/stinging sensation (reported in 29 of 294 patients), scalp pustules, tingling, and folliculitis 4
• Strategies to minimize corticosteroid-related adverse effects include:
  • Using the minimum effective potency for the shortest duration necessary 7, 8
  • Implementing intermittent therapy (weekend-only or every-other-day application) for maintenance 6, 7
  • Rotating or combining with non-steroidal agents like vitamin D analogues or tazarotene 6, 9
• Systemic corticosteroids should generally be avoided in psoriasis as they can cause disease flare during taper 3

Practical Treatment Algorithm

1. For mild psoriasis (<3% BSA):

   • Start with topical corticosteroids appropriate for the location (high potency for thick plaques, lower potency for face/intertriginous areas) 2, 5
   • Consider combination with vitamin D analogues for enhanced efficacy 1, 2
   • For maintenance, use intermittent corticosteroid therapy or transition to non-steroidal alternatives 6, 7

2. For moderate-to-severe psoriasis (≥3% BSA or significant symptoms):

   • Consider phototherapy as first-line systemic approach 3
   • For those requiring systemic therapy, options include methotrexate, cyclosporine, acitretin, or biologics 1, 3
   • Continue topical therapy as adjunctive treatment to enhance efficacy of systemic agents 1, 8

3. For special sites:

   • Scalp: Use solutions, foams, or shampoos containing corticosteroids, vitamin D analogues, or combination products 2, 5
   • Face/intertriginous areas: Use low-potency corticosteroids or calcineurin inhibitors 2, 5
   • Nails: Consider vitamin D analogues, tazarotene, or intralesional corticosteroids 5