What are the treatment options for psoriasis?

Psoriasis Treatment

For mild psoriasis (<5% body surface area), start with topical corticosteroids combined with vitamin D analogues as first-line therapy; for moderate-to-severe disease (≥5% BSA), initiate phototherapy with narrowband UVB, and escalate to biologic agents (IL-17, IL-23, or IL-12/23 inhibitors) for inadequate response or severe disease. 1, 2

Disease Severity Classification

Psoriasis severity determines your treatment approach and must be assessed before initiating therapy:

• Mild disease is defined as <5% BSA involvement 1, 2
• Moderate-to-severe disease is ≥5% BSA or involvement of vulnerable areas (face, genitals, hands, feet) 1, 2
• Symptomatic psoriasis (pain, bleeding, itching) warrants systemic or phototherapy consideration even with limited BSA 1, 2
• Quality of life impact should drive treatment intensity regardless of physical extent 1, 2

Treatment Algorithm for Mild Psoriasis

First-line topical therapy:

• Topical corticosteroids are the cornerstone of mild psoriasis treatment 1, 2, 3
• Vitamin D analogues (calcipotriene) used alone or in combination with corticosteroids 1, 2
• Combination products (calcipotriene plus betamethasone dipropionate) enhance efficacy and reduce irritation compared to monotherapy 1, 2

Second-line topical options:

• Tazarotene (topical retinoid) for patients not responding to first-line agents 4
• Coal tar preparations, though less commonly used due to cosmetic concerns 4, 5
• Anthralin (dithranol) for localized plaques 6, 4

Critical caveat: Long-term use of potent topical corticosteroids causes skin atrophy, striae, and telangiectasia—use intermittent application or switch to vitamin D analogues for maintenance 1, 2

Treatment Algorithm for Moderate-to-Severe Psoriasis

First-line: Phototherapy

• Narrowband UVB is the preferred initial phototherapy 1, 2, 4
• PUVA (psoralen plus UVA) as an alternative phototherapy option 1, 2, 4
• Apply vitamin D analogues after phototherapy sessions to avoid inactivation 2

Second-line: Traditional systemic agents

• Methotrexate requires monitoring of complete blood count, liver function tests, and serum creatinine 1, 4
• Cyclosporine requires monitoring of blood pressure, renal function, and lipid profile 1, 4
• Acitretin (oral retinoid) for patients who cannot use other systemic agents 1, 4

Third-line: Biologic agents (preferred for moderate-to-severe disease)

• IL-17 inhibitors, IL-23 inhibitors, and IL-12/23 inhibitors are more effective and better tolerated than conventional systemic agents 1, 2, 7
• TNF inhibitors remain effective options, particularly for patients with concurrent psoriatic arthritis 2, 4
• Biologics target specific inflammatory pathways with superior safety profiles compared to traditional systemic agents 7

Site-Specific Treatment Considerations

Scalp psoriasis:

• Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 1, 2
• Clobetasol propionate topical solution is effective but monitor for scalp pustules, burning, and folliculitis 3

Facial and intertriginous psoriasis:

• Low-potency corticosteroids only to avoid skin atrophy in these sensitive areas 1, 2

Palmoplantar pustular psoriasis:

• Moderately potent topical corticosteroids, coal tar, or dithranol 1
• Consider systemic etretinate for severe cases 1

Treatment for Psoriatic Arthritis

Mild joint symptoms:

• NSAIDs as initial therapy 1, 4

Moderate-to-severe joint involvement:

• DMARDs (methotrexate, sulfasalazine, leflunomide) as first-line systemic therapy 1, 4
• TNF inhibitors for inadequate response to at least one DMARD 1, 4
• TNF inhibitors like adalimumab effectively treat both skin and joint symptoms simultaneously 2

Combination and Rotational Strategies

Combination therapy advantages:

• Topical corticosteroids plus vitamin D analogues enhance efficacy and reduce irritation compared to monotherapy 1, 2
• Oral fish oil supplementation may augment effects of topical, systemic, and phototherapy for chronic plaque psoriasis 6

Rotational therapy:

• Switch between treatment modalities every 1-2 years to minimize cumulative toxicity of individual treatments 2, 8
• This approach allows 4-5 years before returning to the first therapy, reducing long-term adverse effects 8

Critical Pitfalls to Avoid

Systemic corticosteroids are absolutely contraindicated:

• They cause severe disease flare during taper and may provoke pustular psoriasis 1, 2, 4

Pregnancy considerations:

• All commonly used systemic agents are absolutely contraindicated in pregnancy 1
• Careful contraception counseling is mandatory before initiating systemic therapy 1

Drug-induced psoriasis triggers:

• Beta-blockers, NSAIDs, lithium, chloroquine, and mepacrine can precipitate or worsen psoriasis 2
• Review medication lists and consider alternatives when possible 2

Monitoring failures:

• Do not prescribe systemic agents without establishing regular monitoring protocols 1, 4
• Unsupervised repeat prescriptions of potent topical corticosteroids lead to skin atrophy 2

Adjunctive and Alternative Approaches

Evidence-based supplements:

• Oral curcumin supplementation may benefit as adjunctive therapy, though bioavailability is poor 6
• Fish oil/omega-3 fatty acids can be considered as additional supplementation, but select mercury-free products 6

Approaches with insufficient evidence:

• Oral vitamin D supplementation does not improve disease activity—use topical vitamin D analogues instead 6
• Oral zinc supplementation did not independently improve psoriasis 6
• Gluten-free diet should only be considered for patients with diagnosed celiac disease 2

Stress reduction:

• Mindfulness meditation and stress reduction techniques can improve psoriasis severity in some patients 2