Psoriasis Treatment Options
The most effective approach to psoriasis treatment should be tailored 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) 1, 2
- Patients with symptomatic psoriasis (pain, bleeding, itching) should be considered for systemic or phototherapy even if BSA involvement is limited 2
- 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
For Mild Psoriasis (<5% BSA)
- First-line treatment includes topical therapies such as:
For Moderate-to-Severe Psoriasis (≥5% BSA)
- First-line treatment includes phototherapy:
- Second-line options include traditional systemic agents:
- Third-line options include biologic agents:
Special Considerations for Specific Psoriasis Types
Scalp Psoriasis
- Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 4, 2
- Coal tar shampoos can be effective 3
Facial and Intertriginous Psoriasis
- Low-potency corticosteroids are recommended to avoid skin atrophy 4, 2
- Tacalcitol ointment or calcipotriene combined with hydrocortisone 4
Psoriatic Arthritis
- For mild joint symptoms, NSAIDs are recommended 2
- For moderate-to-severe joint involvement, DMARDs such as methotrexate are recommended 2
- For inadequate response to at least one DMARD, TNF inhibitors like adalimumab are effective for both skin and joint symptoms 2, 6
Combination and Rotational Strategies
- Combination therapy with topical corticosteroids plus vitamin D analogues enhances efficacy and reduces irritation 1, 5
- Addition of topical agents to systemic therapies can improve outcomes:
- Rotational therapy (switching between treatment modalities every 1-2 years) may minimize cumulative toxicity of individual treatments 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, 2
- Vitamin D analogues should be applied after phototherapy to avoid inactivation 1
- Combination of multiple systemic agents may increase risk of toxicity 1
- Commercial sunbeds are rarely effective for psoriasis and may cause premature skin aging and increased skin fragility 2
- Drugs that may precipitate or worsen psoriasis include alcohol, beta-blockers, NSAIDs, lithium, chloroquine, and mepacrine 1
Alternative Medicine Approaches
- Coal tar preparations are recommended for the treatment of mild to moderate psoriasis 3
- Oral curcumin supplementation may benefit as adjunctive therapy 1
- Mindfulness meditation and stress reduction techniques can improve psoriasis severity in some patients 1
Despite the wide range of available treatments, the goal should be to achieve clear or almost clear skin (≤1% BSA involvement) to maximize quality of life and minimize disease impact 5. The most recent guidelines emphasize the importance of treating to target and regularly reassessing treatment response 1, 2.