Treatment Options for Psoriasis
The most effective treatment approach for psoriasis is 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
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 1, 2
- Quality of life impact should be considered when selecting therapy, as psychological distress can be significant regardless of physical extent 1
Treatment Algorithm Based on Disease Severity
For Mild Psoriasis (<5% BSA, asymptomatic)
- First-line: Topical therapies 1
- Topical corticosteroids (such as clobetasol propionate 0.05% and halobetasol propionate 0.05%) 1, 2, 3
- Vitamin D analogs (calcipotriene, calcitriol) 1, 2
- Combination products (corticosteroids plus vitamin D analogs) enhance efficacy and reduce irritation 1, 2, 4
- Other options: coal tar, anthralin, and salicylic acid 2, 5
For Moderate-to-Severe Psoriasis (≥5% BSA or symptomatic)
- First-line: Phototherapy 1
- Options include narrowband UVB and PUVA 1
- Second-line: Traditional systemic agents 1
- Third-line: Biologic agents 1
Special Considerations for Specific Psoriasis Types
Scalp Psoriasis
- Treatment options include calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 1, 2
- Solutions, foams, and shampoos containing corticosteroids, vitamin D analogs, salicylic acid, coal tar, or anthralin 5
Facial and Intertriginous Psoriasis
- Low-potency corticosteroids are recommended to avoid skin atrophy 1, 2
- Calcineurin inhibitors (tacrolimus, pimecrolimus) are effective alternatives 5
Nail Psoriasis
- Topical vitamin D analogs combined with betamethasone dipropionate, though with limited efficacy due to poor penetration 2, 5
Psoriatic Arthritis
- Treatment options include NSAIDs for mild joint symptoms, DMARDs for moderate-to-severe joint involvement 1
- TNF inhibitors like adalimumab are effective for both skin and joint symptoms 1
Combination and Rotational Strategies
- Combination therapy with topical corticosteroids plus vitamin D analogs enhances efficacy 1, 4
- Weekday/weekend regimens (e.g., calcitriol on weekdays, clobetasol on weekends) can be effective for moderate plaque psoriasis 4
- Adding clobetasol propionate spray to biologic treatments can improve outcomes in patients not fully responding to biologics alone 8
- Rotational therapy (switching between treatment modalities every 1-2 years) may minimize cumulative toxicity 1
Common Pitfalls and Caveats
- Systemic corticosteroids should be avoided in psoriasis as they can cause disease flare during taper 1, 2
- Long-term use of potent topical corticosteroids can cause skin atrophy, striae, and telangiectasia 1, 8
- Vitamin D analogs should be applied after phototherapy to avoid inactivation 1, 2
- Combination of multiple systemic agents may increase risk of toxicity 1
- Drugs that may precipitate or worsen psoriasis include alcohol, beta-blockers, NSAIDs, lithium, chloroquine, and mepacrine 1
- For topical corticosteroids, guidelines recommend regular clinical review, no unsupervised repeat prescriptions, and periods of alternative treatment each year 1
- Methotrexate can cause serious adverse effects including liver function abnormalities, gastrointestinal reactions, stomatitis, and opportunistic infections 6
Treatment Monitoring
- The Psoriasis Area and Severity Index (PASI) is useful for monitoring treatment effectiveness over time 7, 9
- Regular monitoring for adverse effects is essential, particularly with systemic therapies 6
- Disease management is improved with maintaining ideal body weight, avoiding tobacco products, limiting alcohol, and practicing stress reduction techniques 9