What are the treatment options for psoriasis?

Treatment Options for Psoriasis

Disease Severity Classification and Treatment Selection

For mild psoriasis (<5% body surface area and asymptomatic), use topical therapies as first-line treatment; for moderate-to-severe psoriasis (≥5% BSA, symptomatic, or significant quality of life impact), escalate to phototherapy or systemic/biologic agents. 1, 2

• Patients with symptomatic psoriasis (pain, bleeding, itching) require systemic or phototherapy even with limited BSA involvement 1, 2
• Quality of life impact should drive treatment intensity regardless of physical extent 3, 2

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Mild Psoriasis: Topical Therapy Algorithm

First-Line Topical Approach

Start with calcipotriene/betamethasone dipropionate combination product once daily for 4-8 weeks, achieving clear or almost clear status in 48-74% of patients. 1

• High-potency topical corticosteroids (clobetasol propionate 0.05%, halobetasol propionate 0.05%) are effective for mild to moderate psoriasis 1
• Combination therapy with vitamin D analogues plus topical corticosteroids is the most effective approach for mild to moderate psoriasis 1, 2
• Vitamin D analogues (calcipotriene, calcitriol) can be used for up to 52 weeks and are particularly effective for scalp psoriasis 1

Maintenance Strategy After Initial Control

Transition to weekend-only high-potency corticosteroid application (twice daily on weekends) with weekday vitamin D analogue therapy (twice daily on weekdays) to minimize corticosteroid exposure while maintaining efficacy. 1

• Maximum vitamin D analogue use: 100g per week to avoid hypercalcemia 1
• This rotational approach prevents long-term corticosteroid complications 1

Site-Specific Modifications

For facial/intertriginous areas, use low-potency corticosteroids or calcitriol ointment to avoid skin atrophy. 1, 2

• For scalp psoriasis: calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 1, 3
• For nail psoriasis: calcipotriene combined with betamethasone dipropionate reduces nail thickness and hyperkeratosis, though efficacy is limited due to poor nail matrix penetration 1
• Tazarotene 0.1% cream under occlusion for 12 weeks shows comparable efficacy to clobetasol for nail psoriasis 1

Alternative Topical Agents

• Coal tar, anthralin, and salicylic acid are other topical options with varying degrees of efficacy 1, 3
• Tazarotene 0.1% gel once daily plus medium/high-potency corticosteroid demonstrates synergistic effect for 8-16 weeks 1
• Apply tazarotene sparingly to lesions only, avoiding perilesional skin 1

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Moderate-to-Severe Psoriasis: Escalation Algorithm

First-Line: Phototherapy

Narrowband UVB phototherapy is first-line for moderate-to-severe psoriasis, particularly useful in pregnancy. 4, 3, 2

• UV therapy is effective in the majority of patients, cost-effective, and lacks systemic toxicities 4
• Treatment requires two to three times weekly sessions, which may impact work and quality of life 4
• Combination of methotrexate with BB-UVB, NB-UVB, or PUVA produces synergistic effects, allowing enhanced efficacy and reduced UV doses 4
• Acitretin combined with NB-UVB or PUVA increases response rates and decreases cumulative UV exposure 4

Second-Line: Traditional Systemic Agents

For inadequate response to phototherapy, use methotrexate, cyclosporine, or acitretin as second-line systemic therapy. 4, 3, 2

Methotrexate

• Effective for moderate-to-severe psoriasis 3, 2
• Requires regular monitoring of full blood count, liver function tests, and serum creatinine 2
• Conception should be avoided in male patients until 3 months after discontinuation 4
• Can be given subcutaneously to bypass the liver 4

Cyclosporine

• For erythrodermic psoriasis requiring rapid response, initiate cyclosporine 4 mg/kg/day for a short 3-4 month interventional course. 4
• Requires regular monitoring of blood pressure, renal function, and lipid profile 2
• Dramatic improvement typically occurs within 2-3 weeks 4

Acitretin

• Effective for moderate-to-severe psoriasis 3, 2
• Has slow onset of action, may not be sufficiently rapid for systemically ill patients with erythrodermic psoriasis 4
• Absolutely contraindicated in women of childbearing potential due to teratogenicity 4

Third-Line: Biologic Agents

For inadequate response to traditional systemic agents, use biologic therapies including TNF inhibitors, IL-17 inhibitors, IL-23 inhibitors, or IL-12/23 inhibitors. 3, 2

TNF Inhibitors (Adalimumab, Infliximab, Etanercept)

• Adalimumab dosing for plaque psoriasis: 80 mg initial dose, followed by 40 mg every other week starting one week after initial dose 5
• Effective for both skin and joint symptoms in psoriatic arthritis 3
• Increased risk of serious infections including tuberculosis, bacterial sepsis, and invasive fungal infections 5
• Perform test for latent TB; if positive, start TB treatment prior to starting adalimumab 5
• Lymphoma and other malignancies have been reported, including hepatosplenic T-cell lymphoma in adolescents and young adults 5

IL-17 and IL-23 Inhibitors

• Recommended as third-line treatment for moderate-to-severe psoriasis 2
• Varying degrees of efficacy and potential side effects 1

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Combination and Augmentation Strategies

Topicals with Biologics

Adding ultra-high potency (Class I) topical corticosteroid or calcipotriene/betamethasone to biologic therapy accelerates clearance of psoriatic plaques. 2

• Adding topical corticosteroid to standard dose etanercept for 12 weeks is recommended (Level I evidence) 2
• Adding calcipotriene/betamethasone to standard dose adalimumab for 16 weeks accelerates clearance 2
• Adding topical calcipotriene to standard dose methotrexate is recommended (Level I evidence) 2
• All topical corticosteroids can be used in combination with any biologics 2

Phototherapy with Systemic Agents

• Combination of etanercept 50 mg twice weekly and NB-UVB thrice weekly achieved 85% PASI-75 response in 12 weeks 4
• Oral retinoids suppress development of cutaneous squamous cell carcinoma in patients treated with PUVA 4

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Special Populations and Conditions

Erythrodermic Psoriasis

For erythrodermic psoriasis, initiate cyclosporine 4 mg/kg/day as first-line systemic therapy, with dramatic improvement expected within 2-3 weeks. 4

• Initially for all patients: appropriate wet dressings with mid-potency topical steroids and attention to fluid balance with control of ankle edema 4
• Rule out sepsis with blood cultures before initiating immunosuppressive therapy 4
• Taper and discontinue cyclosporine over 2 months while transitioning to maintenance therapy 4
• Alternative first-line options include infliximab, adalimumab, and ustekinumab 4

Psoriatic Arthritis

For mild joint symptoms, use NSAIDs; for moderate-to-severe joint involvement, use DMARDs (methotrexate, sulfasalazine, leflunomide); for inadequate response to at least one DMARD, use TNF inhibitors. 3, 2

• For severe enthesitis that has failed therapies for mild and moderate disease, consider a TNF inhibitor 2

Pregnancy

Narrowband UVB phototherapy should be considered first-line for pregnant women with moderate to severe psoriasis. 4

• All commonly used systemic agents are absolutely contraindicated in pregnancy 2

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Critical Pitfalls to Avoid

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

• Systemic corticosteroids should be avoided in psoriasis as they can cause disease flare during taper 3, 2
• Limit continuous high-potency corticosteroid use to prevent skin atrophy, striae, telangiectasia, and HPA axis suppression 1
• Do not use high-potency corticosteroids on face or flexures—use low-potency agents instead 1
• Long-term use of potent topical corticosteroids can cause skin atrophy, striae, and telangiectasia 2
• Vitamin D analogues should be applied after phototherapy to avoid inactivation 3
• Drugs that may precipitate or worsen psoriasis include alcohol, beta-blockers, NSAIDs, lithium, chloroquine, and mepacrine 3
• Discontinue adalimumab if a patient develops a serious infection or sepsis during treatment 5
• Monitor all patients for active TB during adalimumab treatment, even if initial latent TB test is negative 5