From the Guidelines
Psoriasis treatment involves a combination of topical therapies, phototherapy, and systemic medications depending on severity, with the goal of minimizing morbidity, mortality, and improving quality of life. For mild to moderate psoriasis, first-line treatment includes topical corticosteroids like betamethasone or clobetasol applied once or twice daily for limited periods to reduce inflammation, as recommended by the joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies 1. These can be combined with vitamin D analogs such as calcipotriene to enhance effectiveness while minimizing side effects. Coal tar preparations and salicylic acid can help remove scales. For moderate to severe cases, phototherapy using UVB light 2-3 times weekly for 6-12 weeks often provides significant improvement.
When these approaches are insufficient, systemic treatments become necessary, with methotrexate (starting at 7.5-15mg weekly), cyclosporine (2.5-5mg/kg/day), or oral retinoids like acitretin (10-50mg daily) being prescribed, as outlined in the guidelines of care for the management and treatment of psoriasis with traditional systemic agents 1. For patients with inadequate response, biologic agents targeting specific inflammatory pathways offer effective options, including TNF-alpha inhibitors (adalimumab, etanercept), IL-17 inhibitors (secukinumab, ixekizumab), IL-23 inhibitors (guselkumab, risankizumab), or IL-12/23 inhibitors (ustekinumab), as discussed in the British Association of Dermatologists' guidelines for biologic interventions for psoriasis 2009 1.
Key considerations in treatment selection include:
- Disease severity and affected areas
- Patient preferences and comorbidities
- Potential side effects and the need for regular monitoring
- The importance of lifestyle modifications, such as weight management, smoking cessation, stress reduction, and regular moisturizing, as complementary approaches to improve outcomes, as noted in the guidelines of care for the management of psoriasis and psoriatic arthritis 1.
From the FDA Drug Label
The initial dose of cyclosporine [MODIFIED] should be 2.5 mg/kg/day. Cyclosporine [MODIFIED] should be taken twice daily, as a divided (1.25 mg/kg b.i.d.) oral dose. Patients should be kept at that dose for at least 4 weeks, barring adverse events. If significant clinical improvement has not occurred in patients by that time, the patient's dosage should be increased at 2 week intervals. Based on patient response, dose increases of approximately 0. 5 mg/kg/day should be made to a maximum of 4 mg/kg/day. Treatment should be discontinued if satisfactory response cannot be achieved after 6 weeks at 4 mg/kg/day or the patient's maximum tolerated dose Once a patient is adequately controlled and appears stable the dose of cyclosporine [MODIFIED] should be lowered, and the patient treated with the lowest dose that maintains an adequate response
The treatment for psoriasis with cyclosporine [MODIFIED] is an initial dose of 2.5 mg/kg/day, with possible dose increases up to a maximum of 4 mg/kg/day. The goal is to achieve an adequate response with the lowest possible dose. Treatment should be discontinued if no satisfactory response is achieved after 6 weeks at the maximum tolerated dose 2.
From the Research
Treatment Options for Psoriasis
- Topical treatments, systemic treatments, biologic agents, and phototherapy are all treatment options for psoriasis 3
- Treatment goals include gaining initial and rapid control of the disease, decreasing plaque lesions and percentage of body surface area involved, achieving long-term remission, and minimizing adverse events 4
Topical Treatments
- Topical corticosteroids are effective in treating psoriasis and can be used in combination with other treatments such as calcipotriene, tazarotene, and phototherapy 4, 5
- Topical treatments combining corticosteroids and vitamin D analogues are well-established first-line treatments in mild-to-moderate psoriasis 6
- Other topical treatments include calcipotriene, tazarotene, topical tars, anthralin, keratolytics, and immunomodulators such as pimecrolimus and tacrolimus 4
Systemic Treatments
- Systemic therapies such as methotrexate, acitretin, cyclosporine, and biologic agents are used to treat moderate to severe psoriasis 4, 7
- Acitretin is a valuable tool in the treatment of psoriasis and can be used in monotherapy or in combination with other systemic treatments or biologic agents 7