What is the recommended treatment for an acute psoriasis flare?

Treatment of Acute Psoriasis Flare

For an acute psoriasis flare, initiate high-potency topical corticosteroids combined with vitamin D analogues (calcipotriene) applied twice daily for 2-4 weeks, avoiding systemic corticosteroids which risk severe rebound flares upon discontinuation. 1, 2

Immediate Management Strategy

First-Line Topical Therapy

• Apply high-potency topical corticosteroid (class 2-5) mixed 1:1 with calcipotriene twice daily for initial control during the acute flare 2
• After 2 weeks of control, transition to weekend-only corticosteroid application with weekday calcipotriene to maintain remission while minimizing steroid exposure 2
• Maximum calcipotriol dose is 50 g/week to prevent hypercalcemia 2

Site-Specific Modifications

• For facial or genital involvement: Use tacrolimus 0.1% ointment as first-line monotherapy to avoid skin atrophy from corticosteroids in sensitive areas 2
• For scalp psoriasis: Apply calcipotriol/betamethasone dipropionate suspension once daily for up to 8 weeks 2
• For localized joint involvement: Consider intra-articular glucocorticoid injections for persistently inflamed joints, avoiding injection through psoriatic plaques 3

Critical Warning: Avoid Systemic Corticosteroids

Systemic corticosteroids (including dexamethasone) should be avoided in psoriasis because they precipitate severe rebound flares during or after tapering. 4, 1 This is a common pitfall—while systemic steroids may provide temporary relief, the European League Against Rheumatism explicitly states that "monotherapy with systemic corticosteroids is to be avoided in psoriasis because skin disease can flare during or after taper." 4

• If systemic steroids must be used in exceptional circumstances (e.g., concurrent severe COVID-19), use the lowest effective dose for the shortest duration with gradual tapering 4, 1
• The rebound phenomenon can result in transformation to erythrodermic or pustular psoriasis, which are medical emergencies 1

Escalation Criteria for Systemic Therapy

Escalate beyond topical therapy if any of the following are present:

• Body surface area involvement >5% 2
• Inadequate response to topical therapy after 4-8 weeks 2
• Significant impact on quality of life despite topical treatment 2
• Symptomatic disease (pain, bleeding, itching) 4
• Vulnerable area involvement (face, genitals, hands/feet, nails, scalp, intertriginous areas) 4

Systemic Treatment Options (in order of preference)

For moderate to severe flares requiring systemic therapy:

1. Phototherapy (UVB narrowband) as first-line systemic option—response time 4 weeks 4, 5

2. Methotrexate if significant skin involvement—response time 2 weeks, especially useful for acute generalized pustular psoriasis or erythrodermic psoriasis 4, 3

3. Cyclosporin for rapid control—response time 3 weeks 4

4. Acitretin for erythrodermic/generalized pustular psoriasis—response time 6 weeks 4

5. TNF inhibitors (adalimumab, etanercept, infliximab) for severe disease or inadequate response to DMARDs 3, 6

Adjunctive Measures

• Apply emollients liberally to restore skin barrier function and reduce inflammation 7
• Keratolytic agents (urea, salicylic acid) can enhance penetration of topical therapies, but avoid salicylic acid with calcipotriol as acidic pH inactivates it 2, 7
• Address triggers: stress reduction, avoid skin trauma, treat concurrent infections 8, 9

Monitoring and Follow-Up

• Reassess at 2-4 weeks to determine response to topical therapy 2
• Monitor for corticosteroid-induced complications including skin atrophy, hypopigmentation, and HPA axis suppression with prolonged high-potency use 2
• Never abruptly discontinue high-potency corticosteroids—transition to alternative maintenance therapy (vitamin D analog, calcineurin inhibitor, or weekend-only corticosteroid) 2

Special Populations

For pregnant/breastfeeding patients: Topical corticosteroids and emollients are generally safe; avoid systemic therapies except in consultation with specialists 6

For patients with psoriatic arthritis: Consider methotrexate or TNF inhibitors early as they treat both skin and joint manifestations 3