What is the best treatment for psoriasis?

Best Treatment of Psoriasis

For mild psoriasis (<5% body surface area), start with moderate-to-high potency topical corticosteroids (class 2-5) combined with vitamin D analogs (calcipotriene) for maximum 4 weeks, then transition to weekend-only corticosteroid application with weekday vitamin D analog use for maintenance. 1, 2

Initial Assessment and Disease Severity Classification

Before selecting treatment, assess disease severity using both objective and subjective measures:

• Mild psoriasis: <3% body surface area 2
• Moderate psoriasis: 3-10% body surface area 2
• Severe psoriasis: >10% body surface area 2

Important caveat: Body surface area alone is insufficient—psoriasis affecting palms/soles, face, genitals, or scalp with <5% BSA may still warrant systemic therapy due to significant quality of life impact. 3, 1

Treatment Algorithm for Mild Psoriasis

First-Line Topical Therapy

Combination therapy is superior to monotherapy:

• Topical corticosteroids (class 2-5) PLUS vitamin D analog (calcipotriene) provides synergistic effect and greater efficacy than either agent alone 1, 2
• Apply both agents once daily or mixed together twice daily for first 2 weeks 1
• After initial control, transition to weekend-only corticosteroids with weekday vitamin D analogs to minimize corticosteroid exposure 1, 2

Site-Specific Modifications

• Face, genitals, and intertriginous areas: Use low-potency corticosteroids OR topical calcineurin inhibitors (tacrolimus 0.1%) to avoid skin atrophy 1, 2
• Scalp: Topical corticosteroids (class 1-7) for at least 4 weeks 1
• Body/trunk: Moderate-to-high potency corticosteroids (class 2-5) for maximum 4 weeks 1

Alternative Topical Agents

• Tazarotene (topical retinoid) combined with moderate-to-high potency corticosteroids reduces irritation while enhancing efficacy 1, 2
• Coal tar starting at 0.5-1.0% concentration, gradually increasing to 10% as alternative treatment 1

Critical Precautions for Topical Therapy

• Never exceed 100g of moderate potency corticosteroid per month 1
• Avoid salicylic acid with calcipotriene—acidic pH inactivates calcipotriene 1
• Plan annual periods using alternative treatments to prevent long-term corticosteroid complications 1
• What appears as "tachyphylaxis" is usually poor adherence, not receptor down-regulation 1

Treatment Algorithm for Moderate-to-Severe Psoriasis

For patients with >5% BSA, symptomatic disease, or inadequate response to topical therapy, escalate to phototherapy or systemic agents. 3, 2

Phototherapy Options

• Narrowband UVB is first-line phototherapy with fewer side effects than PUVA 3, 2
• Particularly effective for guttate psoriasis 4
• Must be supervised by trained personnel with regular equipment calibration 4
• Avoid commercial sunbeds (UVA)—they are rarely effective and may cause significant side effects 4

Traditional Systemic Agents

The 2022 GRAPPA guidelines and recent evidence support TNF inhibitors as superior to conventional synthetic DMARDs (csDMARDs) as first-line therapy, particularly in early disease. 3 However, accessibility and cost considerations make the following algorithm practical:

First-line systemic options (consider all before escalating):

1. Methotrexate: 15 mg weekly initially, maximum 25-30 mg weekly 3, 2

   • Most commonly prescribed traditional systemic worldwide 3
   • Requires baseline CBC, liver function tests, serum creatinine with regular monitoring 2
   • Can be dramatically effective even in severe cases 3

2. Cyclosporine: 2.5-5 mg/kg daily 2

   • One of the most effective treatments available 3
   • Response time approximately 3 weeks 2
   • Limited to 1 year use in US (2 years in UK) due to glomerulosclerosis risk 3
   • Requires baseline and regular monitoring of serum creatinine and blood pressure 2

3. Acitretin: 25-50 mg daily 2, 4

   • First-line for pustular and erythrodermic psoriasis 3, 4
   • Response as early as 3 weeks 2
   • Requires baseline CBC, lipids, liver function tests with regular monitoring 2

Biologic Therapy

For moderate-to-severe psoriasis, biologic agents (TNF inhibitors, IL-12/23 inhibitors, IL-17 inhibitors, IL-23 inhibitors) should be considered together with traditional systemics based on patient characteristics, not as last resort. 3, 5

TNF inhibitors are strongly recommended and have superior efficacy to csDMARDs as first-line therapy in early disease. 3

• Adalimumab (Humira) is FDA-approved for moderate-to-severe chronic plaque psoriasis in adults who are candidates for systemic therapy or phototherapy when other systemic therapies are medically less appropriate 6
• All three TNF inhibitors (etanercept, adalimumab, infliximab) show efficacy in phase 3 trials 3
• Etanercept may be less effective in patients with high BMI 3
• Ustekinumab (IL-12/23 inhibitor) shows 67% clearance in palmoplantar pustular psoriasis at 90mg dose 4

JAK Inhibitors and PDE4 Inhibitors

Recent evidence shows no difference in efficacy for PDE4 inhibitors, TNF inhibitors, IL-17 inhibitors, IL-12/23 inhibitors, IL-23 inhibitors, and JAK inhibitors in subgroups with or without concurrent csDMARDs. 3

Special Clinical Scenarios

Pustular Psoriasis

• Acitretin 25-50 mg daily as first-line 3, 2
• Ustekinumab for moderate-to-severe cases 4
• Absolutely avoid systemic corticosteroids—can precipitate erythrodermic or generalized pustular psoriasis upon discontinuation 2, 4

Erythrodermic Psoriasis

• Ustekinumab for moderate-to-severe cases 4
• Cyclosporine, infliximab, or acitretin as alternatives 4

Palmoplantar Pustulosis

• Acitretin and oral PUVA show improvement with no clear superiority 3
• Combination provides superior response 3

Psoriatic Nail Disease

• Evidence is limited with small studies and lack of appropriate controls 3
• Consider systemic therapy if nail disease significantly impacts function 3

Combination and Rotational Therapy Strategies

Combination therapy with agents having different mechanisms of action can maximize efficacy while minimizing toxicity. 7

• Methotrexate can be combined with all approved biologic agents 3
• Methotrexate suppresses antibodies against monoclonal TNF inhibitors (adalimumab, infliximab) 3
• Rotational therapy: Use each treatment for 1-2 years then switch to minimize cumulative toxicity—may be 4-5 years before returning to first therapy 8

Critical Medications to Avoid

Systemic corticosteroids should NEVER be used as monotherapy in psoriasis—they cause disease flare during or after taper and can precipitate pustular or erythrodermic psoriasis. 3, 1, 2, 4

Other medications to avoid:

• Lithium, chloroquine, mepacrine: Associated with severe, potentially fatal psoriasis deterioration 1
• Beta-blockers and NSAIDs may worsen psoriasis in some patients 1
• Alcohol can exacerbate disease 1

When to Refer to Dermatology

• Most patients with chronic stable plaque psoriasis and guttate psoriasis can be managed in primary care 1
• Refer patients requiring systemic agents to dermatology due to potential toxicity requiring specialized monitoring 1
• Consider referral for moderate-to-severe disease (>5% BSA) or disease significantly impacting quality of life 3

Monitoring Requirements Summary

All systemic agents require strict monitoring protocols:

• Methotrexate: Baseline and regular CBC, liver function, creatinine 2
• Cyclosporine: Baseline and regular creatinine, blood pressure 2
• Acitretin: Baseline and regular CBC, lipids, liver function 2
• Biologics: Screen for tuberculosis, hepatitis B, and infections before initiation 6

Common Pitfalls

• Prescribing refills of topical corticosteroids without medical supervision 1
• Using systemic corticosteroids for psoriasis management 2, 4
• Failing to assess quality of life impact in patients with <5% BSA 3
• Not considering biologic therapy early enough in disease course 3, 5
• Combining salicylic acid with calcipotriene 1