What is the guideline treatment for psoriasis?

Guideline Treatment for Psoriasis

The first-line treatment for psoriasis 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

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
• 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

Treatment Algorithm Based on Disease Severity

Mild Psoriasis (<5% BSA)

• First-line treatment includes topical therapies such as:
  • Topical corticosteroids - classified into 7 potency categories, with ultra-high potency (class 1) for thick plaques and lower potency for sensitive areas 2
  • Vitamin D analogs (calcipotriene, calcitriol) - maximum 100g per week to avoid hypercalcemia 3
  • Combination products (calcipotriene/betamethasone dipropionate) - simplifies regimen and improves compliance 3
  • Topical retinoids (tazarotene) - can be corticosteroid-sparing but may cause irritation 3
• Secondary options include:
  • Coal tar - start with concentrations of 0.5-1.0% and increase to maximum 10% 3
  • Anthralin (dithranol) - start at 0.1-0.25% concentration and increase as tolerated 3
  • Salicylic acid - useful for thick, scaly plaques 3

Moderate-to-Severe Psoriasis (≥5% BSA)

• First-line treatment includes phototherapy:
  • Narrowband UVB 1
  • PUVA (psoralen plus UVA) 1
  • 308-nm excimer laser for localized resistant areas 3
• Second-line options include traditional systemic agents:
  • Methotrexate - 15 mg weekly initially, maximum 25-30 mg weekly 4
  • Cyclosporine - 2.5-5 mg/kg daily 4
  • Acitretin - 25-50 mg daily, particularly effective for pustular psoriasis 4
• Third-line options include biologic agents:
  • TNF inhibitors (adalimumab) - for moderate to severe plaque psoriasis 5
  • IL-17 inhibitors 1
  • IL-23 inhibitors 1
  • IL-12/23 inhibitors 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
• For resistant cases, consider excimer laser therapy 3

Facial and Intertriginous Psoriasis

• Low-potency corticosteroids are recommended to avoid skin atrophy 1
• Topical calcitriol is less irritating than other vitamin D analogs and better tolerated on sensitive skin areas 3
• Topical tacrolimus may be considered as first-line therapy for intertriginous psoriasis 3

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, 5

Guidelines for Topical Corticosteroid Use

• Regular clinical review is required 3
• No unsupervised repeat prescriptions should be made 3
• No more than 100g of a moderately potent preparation should be applied each month 3
• Periods each year when alternative treatment is employed 3
• Use of very potent or potent preparations should be under dermatological supervision 3

Common Pitfalls and Caveats

• Systemic corticosteroids should be avoided in psoriasis as they can cause disease flare during taper 1
• Long-term use of potent topical corticosteroids can cause skin atrophy, striae, and telangiectasia 1
• Vitamin D analogs should be applied after phototherapy to avoid inactivation 1
• Drugs that may worsen psoriasis include alcohol, beta-blockers, NSAIDs, lithium, chloroquine, and mepacrine 3
• Combination of multiple systemic agents may increase risk of toxicity 1
• Tachyphylaxis (decreased efficacy with continued use) may occur with prolonged continuous corticosteroid use 2

Combination and Rotational Strategies

• Combination therapy with topical corticosteroids plus vitamin D analogs enhances efficacy and reduces irritation 1
• Rotational therapy (switching between treatment modalities every 1-2 years) may minimize cumulative toxicity of individual treatments 1
• For patients who fail to respond to one topical agent, trying alternative topical agents before considering more aggressive management is recommended 3