What are the evidence-based treatment options for psoriasis?

Evidence-Based Treatment of Psoriasis

Disease Severity Classification and Initial Treatment Selection

For mild psoriasis (<5% body surface area), start with topical corticosteroids combined with vitamin D analogs as first-line therapy, specifically the fixed-combination calcipotriene/betamethasone dipropionate product which demonstrates superior efficacy to either agent alone. 1, 2

• Mild psoriasis is defined as typically <5% BSA involvement, while moderate-to-severe disease is ≥5% BSA or involvement of vulnerable areas (face, genitals, hands, feet) 1
• Patients with symptomatic psoriasis causing pain, bleeding, or itching should be considered for systemic or phototherapy even with limited BSA involvement 1
• Quality of life impact must drive treatment decisions, as psychological distress can be severe regardless of physical extent 1

Topical Therapy Algorithm for Mild Psoriasis

Use ultra-high potency topical corticosteroids (Class 1) for thick plaques on the body, and lower potency formulations for sensitive areas including the face, intertriginous regions, and genitals. 1, 3

First-Line Topical Options:

• Combination calcipotriene/betamethasone dipropionate: This fixed-combination product simplifies regimens, improves compliance, and shows the highest efficacy in Cochrane reviews compared to monotherapy with either agent 1, 2
• Topical corticosteroids alone: Classified into 7 potency categories; ultra-high potency (Class 1) for thick plaques, lower potency for face and intertriginous areas 1
• Vitamin D analogs (calcipotriene, calcitriol): Maximum 100g per week to avoid hypercalcemia; calcitriol is less irritating and better tolerated on sensitive skin 1

Critical Safety Guidelines for Topical Corticosteroids:

• Regular clinical review is mandatory with no unsupervised repeat prescriptions 1
• No more than 100g of moderately potent preparation should be applied monthly 1
• Long-term use of potent topical corticosteroids causes skin atrophy, striae, and telangiectasia 1
• Systemic corticosteroids must be avoided in psoriasis as they cause disease flare during taper 1, 4

Location-Specific Topical Therapy:

• Scalp psoriasis: Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks; excimer laser for resistant cases 1
• Facial and intertriginous psoriasis: Low-potency corticosteroids or topical calcitriol to avoid atrophy 1
• Palmoplantar psoriasis: When intensive topical therapy under occlusion or photochemotherapy fails, systemic therapies (methotrexate, cyclosporine, oral retinoids) are justified despite small BSA involvement due to severe quality of life impact 3

Phototherapy for Moderate-to-Severe Psoriasis

For moderate-to-severe psoriasis (≥5% BSA), narrowband UVB phototherapy is the first-line treatment option. 1, 4

• Narrowband UVB and PUVA (psoralen plus UVA) are both effective first-line phototherapy options 1
• 308-nm excimer laser is recommended for localized resistant areas 1
• Soak PUVA (15-30 minutes in methoxsalen solution) is particularly effective for palmoplantar disease 3
• Vitamin D analogs should be applied after phototherapy to avoid inactivation 1

Systemic Therapy for Moderate-to-Severe Psoriasis

When phototherapy is insufficient or contraindicated, initiate traditional systemic agents including methotrexate, cyclosporine, or acitretin based on patient-specific factors and comorbidities. 4, 3

Cyclosporine:

• For erythrodermic psoriasis with systemic illness, cyclosporine 3-5 mg/kg/day is the logical first choice due to rapid and predictable onset of action 3
• Short 3-4 month "interventional" courses are appropriate for acute flares 3
• Exercise caution in elderly patients, those with renal disease, hypertension, or on medications affecting cyclosporine levels 3

Methotrexate:

• Effective for moderate-to-severe psoriasis but requires upward dose titration which may limit usefulness in patients requiring rapid response 3
• Subcutaneous administration bypasses the liver and may be preferable 3
• Avoid in patients with hepatic and renal disease 3
• Male patients should avoid conception until 3 months after discontinuation 3

Acitretin:

• Effective for palmoplantar psoriasis, particularly pustular variants 3
• Slow onset of action limits usefulness in erythrodermic psoriasis requiring rapid control 3
• Absolutely contraindicated in women of childbearing potential due to teratogenicity 3
• Elevated triglycerides can be managed with fibrates; elevated cholesterol with statins (caution with combination due to rhabdomyolysis risk) 3

Biologic Therapy for Severe Psoriasis

For patients with severe psoriasis inadequately controlled by traditional systemic agents, or those with psoriatic arthritis, TNF inhibitors (such as adalimumab) are effective for both skin and joint symptoms. 5, 6

Adalimumab Dosing:

• Adults with plaque psoriasis: 80 mg initial dose, followed by 40 mg every other week starting one week after initial dose 6
• Psoriatic arthritis: 40 mg every other week; some patients not receiving methotrexate may benefit from 40 mg weekly or 80 mg every other week 6

Critical Safety Warnings for TNF Inhibitors:

• Increased risk of serious infections leading to hospitalization or death, including tuberculosis, bacterial sepsis, and invasive fungal infections 6
• Perform test for latent TB; if positive, start TB treatment prior to starting adalimumab 6
• Monitor all patients for active TB during treatment, even if initial latent TB test is negative 6
• Lymphoma and other malignancies, some fatal, have been reported in patients treated with TNF blockers 6
• Discontinue if patient develops serious infection or sepsis 6

Combination and Rotational Strategies

Combination therapy with topical corticosteroids plus vitamin D analogs enhances efficacy and reduces irritation compared to monotherapy. 1

• Rotational therapy (switching between treatment modalities every 1-2 years) may minimize cumulative toxicity of individual treatments 1
• Topical therapies can be used adjunctively with phototherapy, systemic agents, or biologics to enhance outcomes 7
• Avoid combining multiple systemic agents due to additive toxicity risk 4

Adjunctive and Alternative Approaches

Mindfulness meditation and stress reduction techniques can improve psoriasis severity in some patients and should be discussed as adjunctive therapy with interested patients. 3

• Oral curcumin supplementation may benefit as adjunctive therapy 5
• Biofeedback and relaxation techniques may improve symptoms in mild psoriasis 3
• Gluten-free diet should only be considered for patients diagnosed with celiac disease 5
• Topical Aloe vera may have efficacy in mild psoriasis for patients without allergy 3

Drugs That Worsen Psoriasis

Avoid or carefully monitor the following medications that may precipitate or worsen psoriasis: alcohol, beta-blockers, NSAIDs, lithium, chloroquine, and mepacrine. 1, 5

Common Pitfalls to Avoid

• Never use systemic corticosteroids in psoriasis due to rebound flare risk 1, 4
• Do not prescribe topical corticosteroids without regular clinical review and monitoring 1
• Avoid trimethoprim-sulfamethoxazole and other antibiotics that interact with methotrexate in patients with erythrodermic psoriasis on MTX 3
• Do not start TNF inhibitors during active infection 6
• Recognize that paradoxical psoriasis (particularly palmoplantar pustular) can occur with TNF-alfa antagonist treatment 3