What is the most appropriate first-line treatment for a patient with plaque psoriasis covering 7% of their Body Surface Area (BSA)?

First-Line Treatment for Plaque Psoriasis with 7% BSA

For a patient with plaque psoriasis covering 7% of body surface area (BSA), topical therapy with potent corticosteroids with or without vitamin D analogues is the most appropriate first-line treatment. 1

Treatment Algorithm for Moderate Plaque Psoriasis (5-10% BSA)

First-Line Options:

• Topical therapies should be initiated as the first-line treatment for patients with 7% BSA involvement 1
  • High-potency topical corticosteroids (with or without vitamin D analogues like calcipotriene/calcitriol) 1
  • These can be applied once or twice daily to affected areas 1

Second-Line Options (if topicals fail):

• Phototherapy - particularly narrowband UVB (NB-UVB) 1
  • Can be used as monotherapy or in combination with topicals 1
  • Particularly effective for widespread but moderate disease 1

Third-Line Options (if above fail):

• Conventional systemic agents:

  • Methotrexate (15-25 mg weekly) 1, 2
  • Cyclosporine (2.5-5 mg/kg daily) 1, 2
  • Acitretin (25-50 mg daily) 1

• Biologics (reserved for when conventional systemics fail or are contraindicated):

  • TNF inhibitors (etanercept, adalimumab, infliximab) 1
  • IL-12/23 inhibitor (ustekinumab) 1
  • IL-17 inhibitors (secukinumab, ixekizumab) 3, 2

Rationale for Recommendation

7% BSA involvement falls into the moderate category of psoriasis (3-10% BSA is considered moderate) 1, 3. According to guidelines, topical therapy remains the mainstay of treatment for this level of disease severity 1.

The British Association of Dermatologists guidelines specify that biologics should be reserved for more severe disease that has failed conventional therapies 1. Similarly, the American Academy of Dermatology guidelines recommend a step-wise approach, starting with topicals for moderate disease 1.

Important Clinical Considerations

• Combination topical therapy (corticosteroid plus vitamin D analogue) is more effective than either agent alone 1
• Treatment rotation may be necessary to prevent tachyphylaxis with topical corticosteroids 1
• Special sites such as face, genitals, hands/feet may require different approaches even with lower BSA 1
• Patient adherence to topical therapy is crucial for success - ointments are more effective but creams may improve compliance 1

Pitfalls to Avoid

• Overtreatment: Starting with biologics for moderate disease (7% BSA) without trying topicals first is not cost-effective and exposes patients to unnecessary risks 1
• Undertreatment: Failing to escalate therapy if topicals don't provide adequate response after 2-3 months 1
• Neglecting quality of life impact: Even with "only" 7% BSA, if the disease significantly impacts quality of life or involves sensitive areas, more aggressive therapy may be warranted 1
• Corticosteroid side effects: Long-term use of potent topical steroids can cause skin atrophy, striae, and systemic absorption; consider steroid-sparing approaches for maintenance 1

The evidence strongly supports starting with topical therapy for a patient with 7% BSA plaque psoriasis, with clear pathways for escalation if this approach fails to achieve adequate disease control.