Treatment Options for Psoriasis
For optimal management of psoriasis, treatment should be selected 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 and Treatment Selection
- Psoriasis severity is categorized as mild (<5% body surface area [BSA]) or moderate-to-severe (≥5% BSA or involvement of vulnerable areas) 1, 3
- 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 1, 2
Treatment Algorithm Based on Disease Severity
Mild Psoriasis (<5% BSA)
- First-line: Topical therapies 1, 2, 3
- Topical corticosteroids (varying potencies based on location)
- Vitamin D analogues (calcipotriene)
- Combination products (corticosteroid + vitamin D analogue)
- Second-line: Alternative topical options 3
- Coal tar preparations
- Dithranol (anthralin)
- Salicylic acid
- Tazarotene
Moderate-to-Severe Psoriasis (≥5% BSA)
- First-line: Phototherapy 1, 2, 3
- Narrowband UVB
- PUVA (psoralen + UVA)
- Second-line: Traditional systemic agents 1, 2, 3
- Methotrexate
- Cyclosporine
- Acitretin
- Third-line: Biologic agents 1, 2
- TNF inhibitors (e.g., adalimumab)
- IL-17 inhibitors
- IL-23 inhibitors
- IL-12/23 inhibitors
Special Considerations for Specific Psoriasis Types
Scalp Psoriasis
- Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 1
- Medicated shampoos containing salicylic acid or tar 4
Facial and Intertriginous Psoriasis
- Low-potency corticosteroids to avoid skin atrophy 1, 2
- Calcineurin inhibitors as steroid-sparing agents 3
Palmoplantar Pustular Psoriasis
- Moderately potent topical corticosteroids, coal tar, dithranol, or systemic etretinate 1
Treatment for Psoriatic Arthritis
- For mild joint symptoms: NSAIDs 1, 2
- For moderate-to-severe joint involvement: DMARDs such as methotrexate, sulfasalazine, and leflunomide 1, 3
- For inadequate response to at least one DMARD: TNF inhibitors like adalimumab 1, 5
Treatment Strategies for Optimal Outcomes
- Combination therapy with topical corticosteroids plus vitamin D analogues enhances efficacy and reduces irritation 1
- Rotational therapy (switching between treatment modalities every 1-2 years) may minimize cumulative toxicity of individual treatments 2, 6
- Maintenance therapy with intermittent topical steroid application or vitamin D analogues can help prolong remission 1
Common Pitfalls and Caveats
- Systemic corticosteroids should be avoided in psoriasis as they can cause disease flare during taper 1, 3
- Long-term use of potent topical corticosteroids can cause skin atrophy, striae, and telangiectasia 1
- Commercial sunbeds are rarely effective for psoriasis and may increase skin cancer risk 1
- All commonly used systemic agents are absolutely contraindicated in pregnancy 1
- Biologics carry risks of serious infections and malignancy, requiring careful patient selection and monitoring 5, 7
Monitoring Requirements for Systemic Therapies
- For methotrexate: Regular monitoring of full blood count, liver function tests, and serum creatinine 1
- For cyclosporine: Regular monitoring of blood pressure, renal function, and lipid profile 1
- For biologics like adalimumab: Screen for tuberculosis before initiation and monitor for infections during treatment 5