What are the treatment options for psoriasis?

Treatment Options for Psoriasis

Disease Severity Classification and Treatment Selection

Tailor psoriasis treatment based on disease severity: use topical therapies for mild disease (<5% body surface area), phototherapy for moderate disease, and systemic or biologic agents for moderate-to-severe disease (≥5% BSA) or when quality of life is significantly impacted. 1, 2, 3

• Even with limited BSA involvement, escalate to systemic therapy or phototherapy if the patient experiences symptomatic disease (pain, bleeding, itching) or significant psychological distress 1, 2, 3
• Vulnerable area involvement (face, genitals, hands, feet) warrants consideration for more aggressive therapy regardless of total BSA 1

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Mild Psoriasis (<5% BSA): Topical Therapies

First-Line Topical Treatment

Start with calcipotriene/betamethasone dipropionate combination product once daily for 4-8 weeks, which achieves clear or almost clear status in 48-74% of patients. 2

• This combination therapy enhances efficacy and reduces irritation compared to monotherapy 1, 3
• After achieving initial control, transition to a maintenance regimen: high-potency corticosteroid twice daily on weekends only, with vitamin D analogue twice daily on weekdays 2
• Maximum vitamin D analogue use is 100g per week to avoid hypercalcemia 2

Site-Specific Modifications

For facial and intertriginous psoriasis, use only low-potency corticosteroids or calcitriol ointment to prevent skin atrophy. 1, 2

• Tacalcitol ointment or calcipotriene combined with hydrocortisone can be used for 8 weeks on facial areas 2
• Never use high-potency corticosteroids on the face or flexures 2

For scalp psoriasis, apply calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks. 1, 2, 3

For nail psoriasis, use calcipotriene combined with betamethasone dipropionate or tazarotene 0.1% cream under occlusion for 12 weeks. 2

• Note that topical agents have limited efficacy for severe nail disease due to poor nail matrix penetration 2

Alternative Topical Agents

• Tazarotene 0.1% gel once daily combined with medium/high-potency corticosteroid for 8-16 weeks increases efficacy while reducing local adverse events 2
• Coal tar, anthralin, and salicylic acid are additional options with varying efficacy 1, 4

Critical Pitfalls to Avoid

Never combine salicylic acid with calcipotriene simultaneously—the acidic pH inactivates calcipotriene completely. 2

• Limit continuous high-potency corticosteroid use to prevent skin atrophy, striae, telangiectasia, and HPA axis suppression 2, 3
• Apply vitamin D analogues after phototherapy sessions to avoid inactivation 1, 3
• Avoid systemic corticosteroids entirely in psoriasis as they cause disease flare during taper 1, 3

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Moderate-to-Severe Psoriasis (≥5% BSA): Systemic Therapies

Treatment Hierarchy

First-line: Phototherapy with narrowband UVB or PUVA 1, 3

Second-line: Traditional systemic agents (methotrexate, cyclosporine, acitretin) 1, 3

• For methotrexate, monitor full blood count, liver function tests, and serum creatinine regularly 3
• For cyclosporine, monitor blood pressure, renal function, and lipid profile regularly 3
• All commonly used systemic agents are absolutely contraindicated in pregnancy 3

Third-line: Biologic agents (IL-17 inhibitors, IL-23 inhibitors, IL-12/23 inhibitors, TNF inhibitors) 1, 3

Combination Strategies for Moderate-to-Severe Disease

Add ultra-high potency (Class I) topical corticosteroid to biologic therapy to accelerate clearance. 3

• Adding clobetasol propionate spray 0.05% to standard dose etanercept for 12 weeks is supported by Level I evidence 3
• Adding calcipotriene/betamethasone to standard dose adalimumab for 16 weeks accelerates plaque clearance 3
• Adding topical calcipotriene to standard dose methotrexate is effective for moderate-to-severe psoriasis 3
• All topical corticosteroids can be combined with any biologic agents 3

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Psoriatic Arthritis Treatment

For mild joint symptoms, start with NSAIDs. 1, 3

For moderate-to-severe joint involvement, use DMARDs (methotrexate, sulfasalazine, leflunomide). 1, 3

For inadequate response to at least one DMARD, escalate to TNF inhibitors, which are effective for both skin and joint symptoms. 1, 3

• For severe enthesitis that has failed therapies for mild and moderate disease, consider a TNF inhibitor 3

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Special Populations

Pediatric Plaque Psoriasis

• Etanercept 0.8 mg/kg (up to maximum 50 mg per dose) once weekly is FDA-approved for pediatric patients 4-17 years of age with moderate to severe plaque psoriasis 5

Palmoplantar Pustular Psoriasis

• Use moderately potent topical corticosteroids, coal tar, dithranol, or systemic etretinate 3

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Monitoring and Long-Term Management

• Rotational therapy (switching between treatment modalities every 1-2 years) may minimize cumulative toxicity 1
• Among PASI 75 responders, retreatment after discontinuation results in similar response rates as initial treatment 5
• Following withdrawal of etanercept, median duration of PASI 75 response is between 1-2 months 5