What are the treatment options for psoriasis exacerbation?

Treatment Options for Psoriasis Exacerbation

For psoriasis exacerbation, the most effective approach is to switch to an alternative biologic therapy when the current treatment fails to achieve minimum response criteria or loses its effectiveness over time. 1

First-Line Treatment Options Based on Disease Severity

Mild Psoriasis (typically <5% BSA)

• Topical therapies are the first-line treatment for mild psoriasis 2
• Combination of calcipotriene and betamethasone dipropionate provides superior efficacy compared to either agent alone with a good safety profile for up to 52 weeks 3
• High-potency topical corticosteroids are effective for short-term management of exacerbations 1, 4
• For sensitive areas (face, intertriginous areas), use lower potency corticosteroids to avoid skin atrophy 5

Moderate to Severe Psoriasis (≥5% BSA or affecting vulnerable areas)

• Biologic therapies are recommended when psoriasis has not responded to topical treatments 1
• Consider changing to an alternative therapy, including another biologic, if any of the following applies:
  • Primary failure (psoriasis does not achieve minimum response criteria)
  • Secondary failure (initial response followed by loss of efficacy)
  • Current therapy cannot be tolerated or becomes contraindicated 1

Biologic Therapy Selection

• Ustekinumab is recommended as a first-line biologic agent for adults with psoriasis 1
• Adalimumab is recommended as a first-line biologic agent, particularly when psoriatic arthropathy is a consideration 1, 6
• Secukinumab can be considered as a first-line biologic agent in adults with psoriasis, with or without psoriatic arthritis 1
• Infliximab should be reserved for very severe disease or when other available biologic agents have failed or cannot be used 1

Dose Escalation Strategies for Biologic Therapy

When psoriasis exacerbates during treatment with biologics, consider dose escalation:

Biologic agent	Suggested dose-escalation strategy
Ustekinumab 45 mg every 12 weeks (<100 kg)	Ustekinumab 90 mg every 12 weeks
Ustekinumab 90 mg every 12 weeks (>100 kg)	Ustekinumab 90 mg every 8 weeks
Adalimumab 40 mg every other week	Adalimumab 40 mg weekly
Etanercept 50 mg once weekly	Etanercept 50 mg twice weekly
Infliximab 5 mg/kg every 8 weeks	Infliximab 5 mg/kg every 6 weeks
[1]

Combination Strategies for Enhanced Efficacy

• Addition of topical therapies to biologic treatment can enhance efficacy:
  • Class 1 (ultrahigh potency) topical corticosteroids added to standard dose etanercept is recommended for moderate to severe psoriasis 1
  • Calcipotriene/betamethasone added to standard dose adalimumab can accelerate clearance of psoriatic plaques 1
  • All topical corticosteroids can be used in combination with any biologics 1

Alternative and Adjunctive Approaches

• Stress reduction techniques, including meditation and cognitive behavioral therapy, can improve psoriasis severity in some patients 1, 2
• Oral curcumin supplementation may benefit patients with psoriasis as adjunctive therapy 1, 2
• For patients with celiac disease, a gluten-free diet may be beneficial 1
• Mindfulness meditation improves outcomes in patients with moderate psoriasis qualifying for phototherapy 1

Important Considerations and Pitfalls

• Systemic corticosteroids should be avoided as they can exacerbate psoriasis upon withdrawal 2, 4
• In rare instances, treatment with corticosteroids (or withdrawal of treatment) can exacerbate psoriasis or provoke the pustular form of the disease 4
• Before starting biologic therapy, screen patients for infections, particularly tuberculosis and fungal infections 6
• Monitor patients on biologics for signs of infection, as these medications can increase infection risk 6
• When transitioning between therapies, consider the pharmacology of both drugs, the patient's clinical circumstances, and the patient's views on risks and benefits 1

Treatment Algorithm for Psoriasis Exacerbation

1. Assess severity and location of psoriasis exacerbation 2
2. For mild exacerbation:
   • Optimize topical therapy with combination of calcipotriene and betamethasone dipropionate 3
   • Consider adding stress reduction techniques 1
3. For moderate to severe exacerbation on current biologic therapy:
   • Evaluate for modifiable factors contributing to poor response (e.g., obesity, poor adherence) 1
   • Consider dose escalation of current biologic if feasible 1
   • If inadequate response, switch to alternative biologic agent 1
4. For severe or refractory cases:
   • Consider infliximab for very severe disease 1
   • Consult with a specialist with expertise in biologic therapy 1