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 analogs as first-line therapy; for moderate-to-severe psoriasis (≥5% BSA), initiate narrowband UVB phototherapy, escalating to traditional systemic agents (methotrexate, cyclosporine, acitretin) if inadequate response, and reserve biologic agents targeting IL-17, IL-23, or IL-12/23 for third-line treatment. 1, 2

Mild Psoriasis (<5% BSA)

First-Line Topical Therapy

• Combination therapy with topical corticosteroids plus vitamin D analogs (such as calcipotriene) is superior to monotherapy, providing enhanced efficacy and reduced irritation. 1, 2
• Coal tar preparations are effective alternatives with Level I-II evidence. 1
• For scalp involvement, use calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks. 1
• For facial and intertriginous areas, apply only low-potency corticosteroids to prevent skin atrophy. 1, 2

Critical Pitfalls to Avoid

• Never use systemic corticosteroids for psoriasis—they cause severe disease flares during taper. 1, 3
• Long-term potent topical corticosteroids cause skin atrophy, striae, and telangiectasia. 1
• Implement regular clinical review with no unsupervised repeat prescriptions, and incorporate periods of alternative treatment each year. 2

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

First-Line: Phototherapy

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

Second-Line: Traditional Systemic Agents

• Methotrexate requires monitoring of complete blood count, liver function tests, and serum creatinine. 1, 3
• Cyclosporine requires monitoring of blood pressure, renal function, and lipid profile. 1, 3
• Acitretin is an alternative oral retinoid option. 1, 3
• All systemic agents are absolutely contraindicated in pregnancy. 1

Third-Line: Biologic Agents

• IL-17 inhibitors (secukinumab, ixekizumab, brodalumab), IL-23 inhibitors (guselkumab, tildrakizumab, risankizumab), and IL-12/23 inhibitors (ustekinumab) are reserved for inadequate response to traditional therapies. 1, 4
• TNF inhibitors like adalimumab (40 mg every other week subcutaneously) are FDA-approved for moderate-to-severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy. 5

Augmentation Strategies for Moderate-to-Severe Disease

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

Special Clinical Scenarios

Psoriatic Arthritis

• For mild joint symptoms, use NSAIDs. 1, 2, 3
• For moderate-to-severe joint involvement, initiate DMARDs (methotrexate, sulfasalazine, leflunomide). 1, 2, 3
• For inadequate response to at least one DMARD, escalate to TNF inhibitors. 1, 2, 3
• TNF inhibitors like adalimumab are effective for both skin and joint symptoms. 2
• For severe enthesitis failing other therapies, consider a TNF inhibitor. 1

Symptomatic Disease Regardless of BSA

• Patients with pain, bleeding, or itching should be considered for systemic therapy or phototherapy even if BSA involvement is limited. 1, 2
• Quality of life impact warrants escalation of therapy regardless of physical extent, as psychological distress can be significant. 1, 2

Palmoplantar Pustular Psoriasis

• Use moderately potent topical corticosteroids, coal tar, dithranol, or systemic etretinate. 1

Rotational and Maintenance Strategies

• Rotational therapy (switching between treatment modalities every 1-2 years) minimizes cumulative toxicity of individual treatments. 2, 6
• Maintenance therapy with intermittent topical steroid application or vitamin D analogs prolongs remission. 1

Drug-Induced Psoriasis Triggers

• Avoid or carefully consider drugs that may precipitate or worsen psoriasis: alcohol, beta-blockers, NSAIDs, lithium, chloroquine, and mepacrine. 2

Biologic Safety Considerations

• Adalimumab carries a boxed warning for serious infections (including tuberculosis, bacterial sepsis, invasive fungal infections) and malignancy risk, including lymphoma. 5
• Perform latent tuberculosis testing before initiating adalimumab; if positive, start TB treatment prior to starting the biologic. 5
• Monitor all patients for active tuberculosis during treatment, even if initial testing is negative. 5
• Discontinue biologic therapy if serious infection or sepsis develops. 5