What is the best medication for psoriasis?

Best Medication for Psoriasis

For most patients with psoriasis, a combination of calcipotriene (vitamin D analog) plus betamethasone dipropionate is the best medication for treating psoriasis, as it provides superior efficacy compared to either agent alone with a good safety profile for up to 52 weeks. 1

Treatment Selection Based on Disease Severity

Mild to Moderate Psoriasis (BSA <5%)

• Topical therapy is first-line treatment for patients with limited body surface area involvement 1
• Recommended topical treatments:
  • Vitamin D analogs + corticosteroid combinations:
    • Calcipotriene 0.005% plus betamethasone dipropionate 0.064% - most effective combination with strong evidence (Grade A recommendation) 1
    • In a 52-week study, 69-74% of patients achieved clear or almost clear status with this combination versus 27% with vehicle control 1
  • Potent topical corticosteroids:
    • Class I-III topical corticosteroids are effective for short-term control 1
    • Clobetasol propionate 0.05% (foam, cream) is highly effective for non-scalp psoriasis 2
  • Vitamin D analogs alone:
    • Calcipotriene, calcitriol, tacalcitol are recommended for long-term use (up to 52 weeks) 1
    • Less effective than potent corticosteroids when used alone 1

Moderate to Severe Psoriasis (BSA >5%)

• Systemic therapy is indicated when psoriasis affects >5% BSA or is in vulnerable areas (face, genitals, hands/feet, nails, scalp) 1
• First-line systemic options:
  • Biologics:
    • TNF inhibitors, IL-17 inhibitors, IL-12/23 inhibitors, and IL-23 inhibitors are strongly recommended 1
    • Newer biologics (IL-17, IL-23 inhibitors) show higher efficacy for skin involvement than TNF inhibitors 1
  • Oral therapies:
    • Methotrexate - effective for both skin and joint disease 1
    • Cyclosporine - rapid acting but limited by nephrotoxicity 1
    • Acitretin - particularly effective for pustular and erythrodermic psoriasis 1
    • JAK inhibitors and PDE4 inhibitors 1

Special Considerations for Different Body Sites

Scalp Psoriasis

• Calcipotriene foam and calcipotriene plus betamethasone dipropionate gel are recommended for 4-12 weeks (Grade A recommendation) 1
• Calcipotriene foam showed 40.9% effectiveness in achieving clear/almost clear status versus 24.2% with vehicle 1

Facial Psoriasis

• Topical tacalcitol ointment or calcipotriene combined with hydrocortisone for 8 weeks (Grade B recommendation) 1
• Treatments containing hydrocortisone are more effective for facial psoriasis 1

Nail Psoriasis

• Topical vitamin D analogs combined with betamethasone dipropionate can reduce nail thickness, hyperkeratosis, onycholysis, and pain 1
• Biologics (TNF inhibitors, IL-17 inhibitors, IL-12/23 inhibitors, IL-23 inhibitors) are strongly recommended for severe nail disease 1

Palmoplantar Psoriasis

• Topical maxacalcitol ointment (not available in US) is recommended as initial treatment 1
• Acitretin is particularly effective for palmoplantar pustular psoriasis 1

Optimal Treatment Regimens

Combination Strategies

• Vitamin D + corticosteroid regimens:
  • Morning high-potency topical corticosteroid and evening topical vitamin D analog (Grade B recommendation) 1
  • Vitamin D analogs twice daily on weekdays with high-potency corticosteroids twice daily on weekends for maintenance (Grade B recommendation) 1
  • These regimens reduce adverse effects of topical corticosteroids and may be more cost-effective 1

Treatment Considerations and Cautions

• Avoid simultaneous use of salicylic acid with calcipotriene as the acidic pH inactivates calcipotriene 1
• When using vitamin D analogs with phototherapy, apply after the phototherapy to avoid inactivation by UVA and blocking of UVB 1
• Tazarotene is contraindicated during pregnancy and should be discontinued if pregnancy is recognized 1
• For biologic therapies, consider comorbidities and activity in other psoriatic domains when selecting agents 1

Monitoring and Safety

• No serious adverse events, including striae or hypothalamic-pituitary-adrenal axis suppression, were observed over 52 weeks with calcipotriene 0.005% and betamethasone 0.064% 1
• Topical corticosteroids can cause skin atrophy with long-term use, but combination with vitamin D analogs may reduce this risk 3
• Systemic treatments require appropriate monitoring for specific adverse effects (e.g., liver function with methotrexate, renal function with cyclosporine) 1, 4

By following this treatment algorithm based on disease severity and location, most patients with psoriasis can achieve significant improvement in their condition, with combination therapy of vitamin D analogs and corticosteroids being the cornerstone for mild-moderate disease and systemic therapies reserved for more severe cases.