What are the treatment options for psoriasis?

Psoriasis Treatment

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 status in 48-74% of patients. 1

For moderate-to-severe psoriasis (≥5% BSA), escalate to phototherapy (narrowband UVB or PUVA) as first-line treatment, followed by traditional systemic agents (methotrexate, cyclosporine, acitretin) if inadequate response, and then biologic agents (IL-17, IL-23, or TNF inhibitors) as third-line options. 2, 3

Critical exception: Even with limited BSA, consider systemic or phototherapy immediately if the patient has symptomatic disease (pain, bleeding, itching) or significant quality of life impairment. 2, 1, 3

Topical Therapy Algorithm for Mild Disease

Initial Treatment (Weeks 1-8)

• First choice: Calcipotriene/betamethasone dipropionate combination product once daily for 4-8 weeks 1
• This combination enhances efficacy 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 (twice daily Monday-Friday) to minimize corticosteroid exposure while maintaining efficacy 1
• Maximum vitamin D analogue use: 100g per week to avoid hypercalcemia 1

Site-Specific Modifications

Face and intertriginous areas:

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

Scalp psoriasis:

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

Nail psoriasis:

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

Systemic Therapy for Moderate-to-Severe Disease

Phototherapy (First-Line)

• Narrowband UVB or PUVA for patients with ≥5% BSA 2, 3

Traditional Systemic Agents (Second-Line)

• Methotrexate: Requires regular monitoring of full blood count, liver function tests, and serum creatinine 3
• Cyclosporine: Requires regular monitoring of blood pressure, renal function, and lipid profile 3
• Acitretin 2, 3

Biologic Agents (Third-Line)

• IL-17 inhibitors, IL-23 inhibitors, IL-12/23 inhibitors 2, 3
• TNF inhibitors (e.g., adalimumab): For moderate-to-severe psoriasis and psoriatic arthritis 2, 4
  • Adalimumab dosing: 80 mg initial dose, followed by 40 mg every other week starting one week after initial dose 4
  • Warning: Increased risk of serious infections (tuberculosis, bacterial sepsis, invasive fungal infections) and malignancies including lymphoma 4
  • Perform latent TB testing before starting; monitor all patients for active TB during treatment 4

Combination Strategies to Enhance Efficacy

Adding topicals to biologics:

• 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

Tazarotene combinations:

• Combining tazarotene 0.1% gel once daily with medium/high-potency corticosteroid 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 Algorithm

Mild joint symptoms:

• NSAIDs 2, 3

Moderate-to-severe joint involvement:

• DMARDs (methotrexate, sulfasalazine, leflunomide) 2, 3

Inadequate response to at least one DMARD:

• TNF inhibitors (e.g., adalimumab) effective for both skin and joint symptoms 2, 3, 4

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

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, not before, to avoid inactivation 2

All commonly used systemic agents are absolutely contraindicated in pregnancy 3

When using combination systemic agents, be aware of increased toxicity risk 2

Alternative Adjunctive Therapies

• Oral curcumin supplementation may benefit as adjunctive therapy 2
• Mindfulness meditation and stress reduction techniques can improve psoriasis severity 2
• Gluten-free diet should only be considered for patients diagnosed with celiac disease 2