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 (<5% body surface area), 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, 2

Treatment Algorithm Based on Disease Severity

For Mild Psoriasis (<5% BSA)

• First-line: Topical therapies 1, 2
  • Topical corticosteroids (varying potencies based on location) 2
  • Vitamin D analogues (calcipotriene, calcitriol) 2
  • Combination products (corticosteroid + vitamin D analogue) 2
• Second-line: Other topical options 3
  • Coal tar preparations 3
  • Anthralin (dithranol) 3
  • Salicylic acid 3

For Moderate-to-Severe Psoriasis (≥5% BSA)

• First-line: Phototherapy 1
  • Narrowband UVB 3
  • PUVA (psoralen plus UVA) 3
• Second-line: Traditional systemic agents 1
  • Methotrexate 3
  • Cyclosporine 3
  • Acitretin 3
• Third-line: Biologic agents 1
  • TNF inhibitors (e.g., adalimumab) 4
  • IL-17 inhibitors 1
  • IL-23 inhibitors 1
  • IL-12/23 inhibitors 1

Special Considerations for Specific Psoriasis Types

• For scalp psoriasis: Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 2
• For facial and intertriginous psoriasis: Low-potency corticosteroids to avoid skin atrophy 2
• For palmoplantar pustular psoriasis: Moderately potent topical corticosteroids (grade III), coal tar, dithranol, or systemic etretinate 3
• For generalized pustular or erythrodermic psoriasis: Hospital admission and systemic agents 3

Treatment for Psoriatic Arthritis

• For mild joint symptoms: NSAIDs 1
• For moderate-to-severe joint involvement: DMARDs (methotrexate, sulfasalazine, leflunomide) 3
• For inadequate response to at least one DMARD: TNF inhibitors 3
• New high-quality data support the superiority of TNF inhibitors over conventional synthetic DMARDs as first-line therapy, particularly in patients with early disease 3

Treatment Strategies for Optimal Outcomes

• Combination therapy with topical corticosteroids plus vitamin D analogues enhances efficacy and reduces irritation 2
• Rotational therapy (switching between treatment modalities every 1-2 years) may minimize cumulative toxicity of individual treatments 5
• Maintenance therapy with intermittent topical steroid application or vitamin D analogues can help prolong remission 2

Common Pitfalls and Caveats

• Systemic corticosteroids should be avoided in psoriasis as they can cause disease flare during taper 1
• Long-term use of potent topical corticosteroids can cause skin atrophy, striae, and telangiectasia 1
• Commercial sunbeds (which emit UVA) are rarely effective for psoriasis and may cause premature skin aging and increased skin fragility 3
• All commonly used systemic agents are absolutely contraindicated in pregnancy 3
• Combination of multiple systemic agents may increase risk of toxicity due to additive effects 3

Monitoring Requirements for Systemic Therapies

• For methotrexate: Regular monitoring of full blood count, liver function tests, and serum creatinine 3
• For cyclosporine: Regular monitoring of blood pressure, renal function, and lipid profile 3
• For biologic agents like adalimumab: Screening for tuberculosis before initiation and monitoring for infections during treatment 4

Despite the chronic nature of psoriasis, appropriate treatment selection based on disease severity and individual factors can effectively manage symptoms and improve quality of life for most patients.