What are the treatment options for psoriasis?

Psoriasis Treatment

Treatment Selection Based on Disease Severity

For mild psoriasis (<5% body surface area), start with topical corticosteroids combined with vitamin D analogues as first-line therapy; for moderate-to-severe psoriasis (≥5% BSA), initiate phototherapy with narrowband UVB, escalating to traditional systemic agents (methotrexate, cyclosporine, acitretin) if inadequate response, and reserve biologic agents (IL-17, IL-23, TNF inhibitors) for third-line treatment. 1, 2

Mild Psoriasis Treatment Algorithm

• Topical combination therapy with corticosteroids plus vitamin D analogues (such as calcipotriene/betamethasone) is the most effective first-line approach, providing enhanced efficacy and reduced irritation compared to monotherapy 1, 3
• High-potency topical corticosteroids like clobetasol propionate 0.05% or halobetasol propionate 0.05% can be used for initial control 3
• Vitamin D analogues (calcipotriene, calcitriol) can be continued for up to 52 weeks for maintenance 3
• Alternative topical agents include coal tar preparations, anthralin, and salicylic acid, though with varying efficacy 2, 3

Important Caveats for Topical Therapy

• Avoid systemic corticosteroids entirely as they cause severe disease flare during taper 1, 2
• Long-term potent topical corticosteroids cause skin atrophy, striae, and telangiectasia 1
• Use low-potency corticosteroids for facial and intertriginous psoriasis to prevent atrophy 1, 3
• Require regular clinical review with no unsupervised repeat prescriptions, and incorporate periods of alternative treatment each year 2

Moderate-to-Severe Psoriasis Treatment Algorithm

First-Line: Phototherapy

• Narrowband UVB or PUVA phototherapy is the initial systemic approach for moderate-to-severe disease 1, 2
• Apply vitamin D analogues after phototherapy to avoid inactivation 2, 3
• Commercial sunbeds are ineffective and may cause premature aging and skin fragility 1

Second-Line: Traditional Systemic Agents

• Methotrexate requires regular monitoring of complete blood count, liver function tests, and serum creatinine 1
• Cyclosporine requires monitoring of blood pressure, renal function, and lipid profile 1
• Acitretin is another option for second-line systemic therapy 1, 2
• All systemic agents are absolutely contraindicated in pregnancy 1

Third-Line: Biologic Agents

• IL-17 inhibitors (secukinumab, ixekizumab, brodalumab) 1, 4
• IL-23 inhibitors (guselkumab, tildrakizumab, risankizumab) 1, 4
• IL-12/23 inhibitors (ustekinumab) 1, 4
• TNF inhibitors (adalimumab, etanercept) for patients with concurrent psoriatic arthritis 1, 5

Combination Strategies to Accelerate Response

• Adding ultra-high potency (Class I) topical corticosteroids to standard-dose etanercept for 12 weeks enhances clearance 1
• Adding calcipotriene/betamethasone to standard-dose adalimumab for 16 weeks accelerates plaque clearance 1
• Adding topical calcipotriene to standard-dose methotrexate improves outcomes 1
• All topical corticosteroids can be combined with any biologic therapy 1

Special Considerations by Location

Scalp Psoriasis

• Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 1, 3
• Vitamin D analogues are particularly effective for scalp involvement 3

Facial Psoriasis

• Tacalcitol ointment or calcipotriene combined with hydrocortisone for 8 weeks 3
• Use only low-potency corticosteroids to avoid atrophy 1, 3

Nail Psoriasis

• Topical vitamin D analogues combined with betamethasone dipropionate, though efficacy is limited due to poor penetration 3

Palmoplantar Pustular Psoriasis

• Moderately potent topical corticosteroids, coal tar, dithranol, or systemic etretinate 1

Psoriatic Arthritis Management

• Mild joint symptoms: NSAIDs as first-line 1, 2
• Moderate-to-severe joint involvement: DMARDs (methotrexate, sulfasalazine, leflunomide) 1, 2
• Inadequate response to ≥1 DMARD: TNF inhibitors (adalimumab per FDA approval for reducing signs/symptoms, inhibiting structural damage, and improving physical function) 1, 5
• Severe enthesitis failing other therapies: Consider TNF inhibitor 1

Indications for Escalation Beyond Topical Therapy

• Symptomatic psoriasis (pain, bleeding, itching) warrants systemic or phototherapy even if BSA <5% 1, 2, 3
• Quality of life impact should trigger escalation regardless of physical extent, as psychological distress can be significant 1, 2
• More than minimal impact on quality of life, inadequate response to localized therapy, or varying degrees of incapacity/disability 3

Rotational Therapy Strategy

• Switching between treatment modalities every 1-2 years may minimize cumulative toxicity of individual treatments 2, 6
• This approach allows 4-5 years before returning to the first therapy, reducing long-term adverse effects 6

Drugs That Worsen Psoriasis

• Avoid or use cautiously: alcohol, beta-blockers, NSAIDs, lithium, chloroquine, and mepacrine 2