What are the treatment options for psoriasis?

Treatment Options for Psoriasis

The most effective approach to psoriasis treatment is 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) 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 Algorithm Based on Disease Severity

Mild Psoriasis (First-Line Options)

• Topical corticosteroids are the mainstay treatment for mild to moderate psoriasis, with various potencies available based on treatment location 1, 3
• Vitamin D analogues (calcipotriene, calcitriol) can be used for up to 52 weeks and are particularly effective for scalp psoriasis 1
• Combination therapy with vitamin D analogues and topical corticosteroids is the most effective approach for mild to moderate psoriasis 1, 4
• Coal tar, anthralin, and salicylic acid are other topical options with varying degrees of efficacy 5, 1

Moderate-to-Severe Psoriasis

• Phototherapy (narrowband UVB and PUVA) is recommended as first-line treatment for moderate-to-severe psoriasis 2
• Traditional systemic agents (methotrexate, cyclosporine, acitretin) are second-line options 2, 3
• Biologic agents (TNF inhibitors, IL-17 inhibitors, IL-23 inhibitors, and IL-12/23 inhibitors) are third-line options for moderate-to-severe psoriasis 2, 6

Special Considerations for Specific Psoriasis Types

Scalp Psoriasis

• Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel can be used for 4-12 weeks 1, 2
• Clobetasol propionate foam has shown effectiveness for scalp psoriasis 7

Facial and Intertriginous Psoriasis

• Low-potency corticosteroids are recommended to avoid skin atrophy 2
• Tacalcitol ointment or calcipotriene combined with hydrocortisone can be used for 8 weeks 1

Psoriatic Arthritis

• For patients with psoriatic arthritis, TNF inhibitors like adalimumab are effective for both skin and joint symptoms 5, 6
• Adalimumab is FDA-approved for psoriatic arthritis at a dose of 40 mg every other week 6

Practical Application of Topical Corticosteroids

• For mild to moderate plaque psoriasis, start with topical corticosteroids like clobetasol propionate 0.05% 7, 8
• Once-daily application is more effective than alternate-day application for complete remission over 6 weeks 8
• Foam preparations of corticosteroids offer cosmetic and pharmacodynamic advantages over creams and ointments 7
• Guidelines for topical corticosteroid use include regular clinical review, no unsupervised repeat prescriptions, and periods of alternative treatment each year 5

Combination and Rotational Strategies

• Combination therapy with topical corticosteroids plus vitamin D analogs enhances efficacy and reduces irritation 1, 4
• Topical corticosteroids can be added to biologic therapy for additional clearing of plaques in patients with moderate to very severe psoriasis 9
• Rotational therapy (switching between treatment modalities) may minimize cumulative toxicity of individual treatments 2

Common Pitfalls and Caveats

• Systemic corticosteroids should 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 4, 9
• Vitamin D analogues should be applied after phototherapy to avoid inactivation 2
• Drugs that may precipitate or worsen psoriasis include alcohol, beta-blockers, NSAIDs, lithium, chloroquine, and mepacrine 5

Remember that psoriasis is a chronic condition requiring long-term management. No cure exists, so treatment aims to induce remission and make the condition tolerable for patients 5. The treatment approach should be tailored based on disease severity, affected areas, and impact on quality of life 1, 2.