What are the treatment options for plaque psoriasis?

Treatment of Plaque Psoriasis

The treatment of plaque psoriasis should follow a stepwise approach based on disease severity, with topical corticosteroids as first-line therapy for mild to moderate disease and biologics for moderate to severe disease. 1, 2

Mild to Moderate Plaque Psoriasis

First-Line Topical Treatments

• Class 1-3 (high to ultra-high potency) topical corticosteroids are recommended for up to 4 weeks for plaque psoriasis not involving intertriginous areas 1, 2
• Efficacy rates for ultra-high potency corticosteroids range from 58% to 92% in randomized controlled trials 1, 3
• Recommended dosing is 1-2 times daily, with appropriate potency selection based on:
  • Disease location (lower potency for face, intertriginous areas) 1, 2
  • Disease severity (higher potency for thicker plaques) 1
  • Patient age (lower potency in elderly, children) 2

Second-Line and Maintenance Topical Treatments

• Vitamin D analogues (calcipotriene/calcipotriol, calcitriol) are recommended for long-term use up to 52 weeks 2, 4
• Tazarotene can be used for 8-12 weeks for mild to moderate psoriasis 1
• Calcineurin inhibitors (tacrolimus, pimecrolimus) are recommended for facial and inverse psoriasis for 4-8 weeks 1

Combination Topical Approaches

• Combination of topical corticosteroids and vitamin D analogues provides superior efficacy to either agent alone 2, 5
• Medium or high-potency topical corticosteroids combined with tazarotene for 8-16 weeks is more effective than tazarotene monotherapy 1
• For maintenance therapy, consider:
  • Vitamin D analogues twice daily on weekdays with high-potency corticosteroids twice daily on weekends 2, 4
  • Morning corticosteroid with evening vitamin D analogue application 2

Moderate to Severe Plaque Psoriasis

Systemic Treatments

• Biologics are recommended as first-line treatment for moderate to severe plaque psoriasis due to their efficacy and acceptable safety profiles 1, 6
• TNF-α inhibitors (etanercept, adalimumab, infliximab) are effective for both skin and joint manifestations 1, 7
• For infliximab, the recommended starting dose is 5 mg/kg administered at weeks 0,2, and 6, then every 8 weeks thereafter 1
• Other biologics target specific cytokines:
  • IL-12/23 inhibitors (ustekinumab) 6
  • IL-17 inhibitors (secukinumab, ixekizumab) 6
  • IL-23 inhibitors (guselkumab, risankizumab) 6

Traditional Oral Treatments

• Methotrexate, acitretin, and cyclosporine are traditional systemic agents for moderate to severe psoriasis 6
• Apremilast (phosphodiesterase 4 inhibitor) is a newer oral option 6

Treatment by Anatomical Site

Scalp Psoriasis

• Topical corticosteroids (classes 1-7) are recommended for at least 4 weeks 1, 2
• Calcipotriene foam and calcipotriene plus betamethasone dipropionate gel are effective for 4-12 weeks 2, 4
• Solutions and foams provide better penetration through hair 8

Facial and Intertriginous Psoriasis

• Lower potency corticosteroids are recommended to minimize adverse effects 2
• Tacrolimus 0.1% can be used for up to 8 weeks for facial psoriasis 1
• Pimecrolimus is recommended for inverse psoriasis for 4-8 weeks 1
• Calcipotriene with hydrocortisone is effective for 8 weeks 2, 4

Nail Psoriasis

• Topical corticosteroids, vitamin D analogues, and tazarotene can be used 8
• Infliximab is recommended for moderate-to-severe nail psoriasis 1

Important Precautions and Limitations

Topical Corticosteroids

• Risk of skin atrophy, striae, and hypothalamic-pituitary-adrenal axis suppression with prolonged use 2, 5
• Tachyphylaxis (decreased effectiveness over time) may occur 2
• Use lower potency agents on face, intertriginous areas, and areas susceptible to steroid atrophy 1

Vitamin D Analogues

• Avoid simultaneous use with salicylic acid as the acidic pH inactivates calcipotriene 2, 4
• If used with phototherapy, apply after treatment as UVA radiation can decrease concentration on skin 9, 4
• For pediatric patients, limit dosage to 50 g/week/m² for calcipotriol and 100 g/week/m² for calcipotriene to prevent hypercalcemia 9, 4

Biologics

• Increased risk of serious infections including tuberculosis, bacterial sepsis, and invasive fungal infections 7
• Screen for latent tuberculosis before initiating therapy 7
• Risk of malignancy, including lymphoma, particularly in children and adolescents 7

Treatment Algorithm Based on Disease Severity

1. Mild Disease (limited body surface area)

   • Start with high-potency topical corticosteroid once or twice daily for 2-4 weeks 1, 2
   • Add or switch to vitamin D analogue for maintenance (up to 52 weeks) 2, 4
   • Consider combination therapy for better efficacy 2

2. Moderate Disease

   • Topical therapy as above, plus consider phototherapy (narrowband UVB) 6
   • If inadequate response, consider adding low-dose systemic therapy 6

3. Severe Disease

   • First-line: Biologics (TNF-α, IL-17, IL-23 inhibitors) 1, 6
   • Alternative: Traditional systemic agents (methotrexate, acitretin, cyclosporine) 6
   • Combination with topical therapy for resistant plaques 1