What are the oral treatment options for psoriasis?

Oral Treatment Options for Psoriasis

The primary oral treatments for psoriasis include methotrexate, acitretin, cyclosporine, and apremilast, with newer targeted therapies like deucravacitinib (TYK2 inhibitor) also available for moderate to severe disease. 1, 2

Traditional Oral Systemic Agents

Methotrexate

• FDA-approved in 1972 and has been used for over four decades in psoriasis treatment 1
• Acts as a competitive inhibitor of dihydrofolate reductase, decreasing folate cofactors required for nucleic acid synthesis 1
• Typically dosed at 15 mg weekly initially, with maximum doses of 25-30 mg weekly 3
• Requires baseline CBC, liver function tests, and serum creatinine with regular monitoring of liver function 3
• Effective for both skin psoriasis and psoriatic arthritis 1

Cyclosporine

• Recommended at doses of 2.5-5 mg/kg daily with response typically seen within 3 weeks 3
• Requires baseline serum creatinine and blood pressure measurements with regular monitoring of both 3
• Particularly useful for rapid control of severe psoriasis but not recommended for long-term use due to nephrotoxicity 1

Acitretin

• Oral retinoid dosed at 25-50 mg daily 3
• Particularly effective for pustular psoriasis 3, 4
• Requires baseline CBC, lipids, and liver function tests with regular monitoring 3
• Absolutely contraindicated in pregnancy due to teratogenicity 3
• Works primarily by decreasing keratinocyte hyperproliferation and restoring normal epidermal differentiation 1

Newer Oral Agents

Apremilast

• Phosphodiesterase-4 inhibitor approved more recently than traditional agents 5, 6
• Has a more favorable safety profile compared to traditional immunosuppressants 2
• Does not require the same intensive laboratory monitoring as methotrexate or cyclosporine 2

Deucravacitinib

• Tyrosine kinase 2 (TYK2) inhibitor representing newer targeted oral therapy 7
• More selective mechanism of action compared to traditional immunosuppressants 7
• Part of the emerging class of oral small molecule inhibitors 2

Alternative Oral Supplements

Fish Oil/Omega-3 Fatty Acids

• May augment the effects of topical, oral-systemic, and phototherapy for chronic plaque psoriasis 1
• Can be considered as an additional supplement in patients with chronic plaque psoriasis 1
• Should be selected free of contaminants like mercury, dioxins, and polychlorinated biphenyls 1, 8
• May reduce platelet aggregation but studies show this doesn't increase bleeding risk during surgery 1

Curcumin

• The active chemical in turmeric that modulates T-helper type 22 cell activity 1
• May benefit patients with psoriasis as adjunctive therapy, though literature is limited 1, 8
• Has low toxicity but poor bioavailability; absorption is enhanced when combined with piperine from black pepper 1

Treatment Selection Considerations

• For mild disease (less than 3% body surface area), topical therapies are generally sufficient 1, 3
• For moderate to severe disease (3% or more body surface area), oral systemic agents or biologics are typically needed 1, 3
• Patients with psoriatic arthritis may benefit from methotrexate or biologics that target TNF-α 1, 3
• Oral agents are often preferred by patients who are uncomfortable with injectable therapies 2

Common Pitfalls and Cautions

• Systemic corticosteroids should be avoided in psoriasis management as they can cause disease flare during taper 4
• Oral vitamin D supplementation is not recommended for psoriasis treatment at dosages that avoid hypercalcemia 1, 8
• Oral zinc supplementation has not shown to independently improve psoriasis 1, 8
• All commonly used systemic agents have contraindications in pregnancy 3
• Combination therapy risks, such as additive toxicity, require careful monitoring 3

Monitoring Requirements

• Methotrexate requires regular liver function monitoring 3
• Cyclosporine requires regular blood pressure and renal function monitoring 3
• Acitretin requires monitoring of lipids and liver function 3
• Newer agents like apremilast generally require less intensive monitoring 2

When selecting an oral treatment for psoriasis, consider disease severity, presence of psoriatic arthritis, comorbidities, and patient preferences regarding administration and monitoring requirements.