What are the treatment options for psoriasis?

Medical Treatment for Psoriasis

Disease Severity Classification and Treatment Selection

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

• Patients with symptomatic psoriasis (pain, bleeding, itching) require systemic or phototherapy regardless of body surface area involvement 1, 2
• Moderate-to-severe psoriasis (≥5% BSA) necessitates phototherapy or systemic agents as first-line treatment 2
• Quality of life impact should drive treatment intensity, not just physical extent 2

First-Line Topical Therapy for Mild Psoriasis

The most effective topical approach combines high-potency corticosteroids with vitamin D analogues, providing synergistic anti-inflammatory and anti-proliferative effects. 1, 3

Initial Treatment Phase (4-8 weeks):

• Apply calcipotriene/betamethasone dipropionate combination product once daily 1
• For trunk and extremities, use high-potency corticosteroids (clobetasol propionate 0.05% or halobetasol propionate 0.05%) 1
• Maximum vitamin D analogue use: 100g per week to avoid hypercalcemia 1

Site-Specific Modifications:

• Facial/intertriginous areas: Use low-potency corticosteroids or calcitriol ointment to prevent skin atrophy 1, 4
• Scalp psoriasis: Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 1, 2
• Nail psoriasis: Calcipotriene combined with betamethasone dipropionate, though efficacy is limited due to poor nail matrix penetration 1

Maintenance Therapy Strategy

After achieving initial control, transition to weekend-only high-potency corticosteroid application with weekday vitamin D analogue therapy to minimize corticosteroid exposure while maintaining efficacy. 1

• Apply high-potency topical corticosteroid twice daily on weekends only 1
• Apply vitamin D analogue twice daily on weekdays 1
• This rotational approach prevents tachyphylaxis and reduces adverse effects 1

Systemic Therapy for Moderate-to-Severe Psoriasis

For patients with ≥5% BSA or inadequate response to topicals, initiate phototherapy (narrowband UVB) as first-line systemic treatment. 2

Traditional Systemic Agents (Second-Line):

• Methotrexate: FDA-approved since 1972, inhibits dihydrofolate reductase and increases endogenous adenosine with anti-inflammatory effects 4
• Cyclosporine: For rapid disease control, requires monitoring of blood pressure and renal function 2
• Acitretin: Works by decreasing keratinocyte hyperproliferation and restoring normal epidermal differentiation 4

Biologic Therapies (Third-Line):

• TNF inhibitors (adalimumab, etanercept), IL-17 inhibitors, IL-23 inhibitors, and IL-12/23 inhibitors for severe disease 2
• Adalimumab dosing: 80 mg initial dose, followed by 40 mg every other week starting one week after initial dose 5

Combination Strategies to Enhance Systemic Therapy

Adding topical corticosteroids to biologic therapy accelerates clearance and improves outcomes. 2, 6

• Adding ultra-high potency (Class I) topical corticosteroid to etanercept for 12 weeks enhances efficacy 2
• Adding calcipotriene/betamethasone to adalimumab for 16 weeks accelerates plaque clearance 2
• Adding topical calcipotriene to methotrexate improves outcomes in moderate-to-severe disease 2

Pediatric Psoriasis Treatment

For children with localized psoriasis, ultra-high-potency topical corticosteroids as monotherapy are effective for short-term treatment. 4

• Dual topical therapy with high-potency steroid and vitamin D analogue is standard practice 4
• Facial/genital psoriasis: Tacrolimus 0.1% ointment is recommended for off-label use 4
• Systemic agents are absolutely contraindicated in pregnancy 2

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 7, 2
• Do not use high-potency corticosteroids on face or flexures—use low-potency agents or tacrolimus instead 1
• Limit continuous high-potency corticosteroid use to prevent skin atrophy, striae, telangiectasia, and HPA axis suppression 1
• Apply vitamin D analogues after phototherapy to avoid inactivation 7
• Screen for tuberculosis before initiating TNF inhibitors due to increased risk of serious infections 5

Monitoring Requirements for Systemic Therapies

• Methotrexate: Regular monitoring of complete blood count, liver function tests, and serum creatinine 2
• Cyclosporine: Regular monitoring of blood pressure, renal function, and lipid profile 2
• TNF inhibitors: Monitor for active tuberculosis during treatment, even if initial latent TB test is negative 5