What are the treatment options for psoriasis?

Treatment Options for Psoriasis

Treatment for psoriasis should be tailored based on disease severity, with topical therapies for mild disease, phototherapy for moderate disease, and systemic/biologic agents for severe disease or those with psoriatic arthritis. 1, 2

Disease Classification and Treatment Selection

• Psoriasis severity is categorized as mild (typically <5% body surface area [BSA]) or moderate-to-severe (≥5% BSA or involvement of vulnerable areas) 1, 2
• Patients with symptomatic psoriasis (pain, bleeding, itching) should be considered for systemic or phototherapy even if BSA involvement is limited 2
• Quality of life impact should be considered when selecting therapy, as psychological distress can be significant regardless of physical extent 1, 3

Treatment Algorithm Based on Disease Severity

Mild Psoriasis (Limited Disease <5% BSA)

• First-line: Topical therapies 1, 2
  • Topical corticosteroids (varying potencies based on location)
  • Vitamin D analogs (calcipotriene, calcitriol)
  • Combination products (corticosteroid + vitamin D analog)
• Second-line options 3
  • Topical tazarotene
  • Coal tar preparations
  • Anthralin (dithranol)
  • Salicylic acid (particularly for thick plaques)

Moderate-to-Severe Psoriasis (≥5% BSA or significant impact)

• First-line: Phototherapy 1
  • Narrowband UVB
  • PUVA (psoralen plus UVA)
• Second-line: Traditional systemic agents 1
  • Methotrexate
  • Cyclosporine
  • Acitretin
• Third-line: Biologic agents 1, 4
  • TNF inhibitors (adalimumab, etanercept, infliximab)
  • IL-17 inhibitors
  • IL-23 inhibitors
  • IL-12/23 inhibitors (ustekinumab)

Special Considerations for Specific Psoriasis Types

Scalp Psoriasis

• Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 2, 5
• Solutions, foams, and shampoos containing corticosteroids, salicylic acid, or coal tar 5

Facial and Intertriginous Psoriasis

• Low-potency corticosteroids to avoid skin atrophy 2, 5
• Calcineurin inhibitors (tacrolimus, pimecrolimus) as steroid-sparing agents 5

Nail Psoriasis

• Topical vitamin D analogs combined with betamethasone dipropionate 5
• Consider systemic therapy for severe nail involvement 5

Psoriatic Arthritis

• NSAIDs for mild joint symptoms 6
• DMARDs (methotrexate, sulfasalazine, leflunomide) for moderate-to-severe joint involvement 6
• TNF inhibitors for inadequate response to at least one DMARD 6, 4

Combination and Rotational Strategies

• Combination therapy with topical corticosteroids plus vitamin D analogs enhances efficacy and reduces irritation 1, 7
• Adjunctive topical therapies with phototherapy or systemic agents can improve outcomes 7
• Rotational therapy (switching between treatment modalities every 1-2 years) may minimize cumulative toxicity of individual treatments 8

Common Pitfalls and Caveats

• Avoid systemic corticosteroids in psoriasis as they can cause disease flare during taper 3
• Long-term use of potent topical corticosteroids can cause skin atrophy, striae, and telangiectasia 9
• Vitamin D analogs should be applied after phototherapy to avoid inactivation 2
• Combination of multiple systemic agents may increase risk of toxicity 3
• Irritant contact dermatitis is common with vitamin D analogs, tazarotene, dithranol, and coal tar 9

Alternative Medicine Approaches

• Oral curcumin supplementation may benefit as adjunctive therapy 1
• Mindfulness meditation and stress reduction techniques can improve psoriasis severity in some patients 1
• Gluten-free diet should only be considered for patients diagnosed with celiac disease 1

By following this evidence-based approach to psoriasis treatment, clinicians can effectively manage the disease while minimizing side effects and improving patients' quality of life.