What are the treatment options for psoriasis?

Psoriasis Treatment Options

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

• Psoriasis severity is categorized as mild (<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 1
• Quality of life impact should be considered when selecting therapy, as psychological distress can be significant regardless of physical extent 2

Treatment Options by Severity

Mild Psoriasis (First-Line Topical Therapies)

• Topical Corticosteroids

  • Most effective for short-term treatment of localized psoriasis 3, 1
  • Available in various potencies; ultra-high potency options include clobetasol propionate 0.05% and halobetasol propionate 0.05% 1
  • Guidelines for use: regular clinical review, no unsupervised repeat prescriptions, no more than 100g of moderately potent preparation monthly, periods without use each year 3
  • Use lower potency formulations for face, flexures, and genitalia to avoid skin atrophy 3, 2

• Vitamin D Analogues

  • Calcipotriene and calcitriol can be used for up to 52 weeks 1
  • Particularly effective for scalp psoriasis 1, 2

• Combination Therapy

  • Combination of vitamin D analogues and topical corticosteroids is the most effective approach for mild to moderate psoriasis 1, 2, 4
  • A Cochrane review showed highest efficacy with fixed combination of calcipotriol and betamethasone dipropionate 4

• Other Topical Options

  • Coal tar preparations are recommended for mild to moderate psoriasis (strength of recommendation: A) 3
  • Anthralin (dithranol) is effective but requires explanation of side effects like irritancy and staining 3
  • Tacrolimus 0.1% ointment is recommended for off-label use as monotherapy for pediatric psoriasis of the face and genital region 3

Moderate to Severe Psoriasis

• Phototherapy

  • First-line treatment for moderate-to-severe psoriasis 2
  • Options include narrowband UVB and PUVA 2
  • Goeckerman therapy (combination of coal tar and UVB) is recommended for certain patients 3

• Traditional Systemic Agents

  • Second-line options include methotrexate, cyclosporine, and acitretin 2, 5
  • Addition of topical calcipotriene to standard dose methotrexate is recommended for moderate to severe psoriasis (strength of recommendation: A) 3

• Biologic Agents

  • Third-line options include TNF inhibitors, IL-17 inhibitors, IL-23 inhibitors, and IL-12/23 inhibitors 2, 6
  • Adalimumab (Humira) is FDA-approved for moderate to severe chronic plaque psoriasis in adults who are candidates for systemic therapy or phototherapy 7
  • The addition of topical therapies to biologics can enhance efficacy:
    • Addition of ultra-high potency topical corticosteroid to standard dose etanercept for 12 weeks is recommended (strength of recommendation: A) 3
    • Addition of calcipotriene/betamethasone to standard dose adalimumab for 16 weeks is recommended to accelerate clearance (strength of recommendation: B) 3

Special Considerations

• Scalp Psoriasis

  • Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel can be used for 4-12 weeks 2

• Facial and Intertriginous Psoriasis

  • Low-potency corticosteroids are recommended to avoid skin atrophy 2
  • Topical calcineurin inhibitors are effective alternatives 3, 8

• Pediatric Psoriasis

  • Topical corticosteroids are technically off-label but frequently used for localized disease 3
  • Weight-based dosing is important for systemic therapies in children 3

Common Pitfalls and Caveats

• Systemic corticosteroids should generally be avoided in psoriasis as they can cause disease flare during taper 2
• Long-term use of potent topical corticosteroids can cause skin atrophy, striae, and telangiectasia 8
• Vitamin D analogues should be applied after phototherapy to avoid inactivation 2
• Drugs that may precipitate or worsen psoriasis include alcohol, beta-blockers, non-steroidal anti-inflammatory agents, lithium, chloroquine, and mepacrine 3
• No cure exists for psoriasis; treatment is suppressive and aimed at inducing remission or making the condition tolerable for the patient 3

Treatment Strategies for Optimal Outcomes

• For patients with stable chronic plaque psoriasis and guttate psoriasis, care can typically be provided by general practitioners 3
• Patients with severe psoriasis requiring systemic agents should be under the continuing supervision of a consultant dermatologist due to potential toxicity 3
• Rotational therapy (switching between treatment modalities) may minimize cumulative toxicity of individual treatments 2
• If a patient does not respond to one topical agent, it is worth trying alternative topical agents before considering more aggressive management 3