What are the treatment options for psoriasis?

Psoriasis Treatment: A Simplified Approach

Treatment Selection Based on Disease Severity

For mild psoriasis (<5% body surface area), start with combination topical therapy using calcipotriene/betamethasone dipropionate once daily for 4-8 weeks, which achieves clear or almost clear skin in 48-74% of patients. 1

Mild Psoriasis (<5% BSA)

First-Line Topical Therapy:

• Use calcipotriene/betamethasone dipropionate combination product once daily for 4-8 weeks as your initial approach 1
• This combination is more effective than either agent alone and reduces irritation compared to monotherapy 2, 3

Maintenance Strategy After Initial Control:

• Transition to weekend-only high-potency corticosteroid (twice daily on weekends) combined with weekday vitamin D analogue therapy (twice daily on weekdays) 1
• This minimizes corticosteroid exposure while maintaining efficacy 1
• Maximum vitamin D analogue use: 100g per week to avoid hypercalcemia 1

Alternative Topical Options:

• Coal tar, anthralin, and salicylic acid have varying efficacy 2
• Tazarotene 0.1% gel once daily plus medium/high-potency corticosteroid shows synergistic effects 1

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

Treatment Escalation Algorithm:

1. First-line: Phototherapy with narrowband UVB or PUVA 2, 3

2. Second-line: Traditional systemic agents 2, 3

   • Methotrexate (requires monitoring of CBC, liver function, serum creatinine) 3
   • Cyclosporine (requires monitoring of blood pressure, renal function, lipid profile) 3
   • Acitretin 2, 3

3. Third-line: Biologic agents 2, 3

   • IL-17 inhibitors
   • IL-23 inhibitors
   • IL-12/23 inhibitors
   • TNF inhibitors (adalimumab 40mg every other week for adults) 4

Important Exception: Consider systemic or phototherapy even for limited BSA if the patient has symptomatic psoriasis (pain, bleeding, itching) or significant quality of life impact 2, 1, 3

Site-Specific Modifications

Scalp Psoriasis:

• Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 2, 1, 3

Facial and Intertriginous Areas:

• Use low-potency corticosteroids or calcitriol ointment to avoid skin atrophy 2, 1, 3
• Never use high-potency corticosteroids on face or flexures 1

Nail Psoriasis:

• Calcipotriene combined with betamethasone dipropionate reduces nail thickness, hyperkeratosis, and onycholysis 1
• Tazarotene 0.1% cream under occlusion for 12 weeks shows comparable efficacy to clobetasol 1
• Note: Topical agents have limited efficacy for severe nail disease due to poor nail matrix penetration 1

Combination Strategies for Enhanced Efficacy

Adding Topicals to Systemic/Biologic Therapy:

• Ultra-high potency (Class I) topical corticosteroid can be added to etanercept for 12 weeks 3
• Calcipotriene/betamethasone can be added to adalimumab for 16 weeks to accelerate clearance 3
• Topical calcipotriene can be added to methotrexate 3
• All topical corticosteroids can be combined with any biologics 3

Tazarotene Combinations:

• Combining tazarotene with medium- or high-potency corticosteroids for 8-16 weeks increases efficacy while reducing local adverse events and prolonging remission 1
• Apply tazarotene sparingly to lesions only, avoiding perilesional skin 1

Psoriatic Arthritis Treatment

Escalation Based on Joint Severity:

• Mild joint symptoms: NSAIDs 2, 3
• Moderate-to-severe joint involvement: DMARDs (methotrexate, sulfasalazine, leflunomide) 2, 3
• Inadequate response to ≥1 DMARD: TNF inhibitors 2, 3
• Severe enthesitis failing other therapies: Consider TNF inhibitor 3

Critical Pitfalls to Avoid

Never combine salicylic acid with calcipotriene simultaneously—the acidic pH inactivates calcipotriene and eliminates its effectiveness. 1

Other Essential Warnings:

• Avoid systemic corticosteroids in psoriasis as they cause disease flare during taper 2, 3
• Limit continuous high-potency corticosteroid use to prevent skin atrophy, striae, telangiectasia, and HPA axis suppression 2, 1, 3
• Apply vitamin D analogues after phototherapy to avoid inactivation 2, 1
• All commonly used systemic agents are absolutely contraindicated in pregnancy 3
• Drugs that may worsen psoriasis include alcohol, beta-blockers, NSAIDs, lithium, chloroquine, and mepacrine 2
• Commercial sunbeds are rarely effective and may cause premature skin aging 3

Biologic Safety Concerns:

• TNF blockers like adalimumab carry increased risk of serious infections (including TB, bacterial sepsis, invasive fungal infections) leading to hospitalization or death 4
• Perform latent TB testing before starting adalimumab; if positive, treat TB first 4
• Lymphoma and other malignancies have been reported, including rare hepatosplenic T-cell lymphoma in adolescents and young adults with inflammatory bowel disease 4
• Discontinue if serious infection or sepsis develops 4