What are the treatment options for psoriasis?

Psoriasis Treatment: Evidence-Based Prescription Approach

Severity-Based Treatment Algorithm

For mild psoriasis (<5% body surface area), prescribe calcipotriene/betamethasone dipropionate combination product once daily for 4-8 weeks, which achieves clear or almost clear status in 48-74% of patients. 1, 2, 3

Defining Disease Severity and Treatment Thresholds

• Mild psoriasis is defined as <5% BSA involvement with minimal symptoms (no pain, bleeding, or significant itching) 1, 2
• Moderate-to-severe psoriasis includes ≥5% BSA, involvement of vulnerable areas (face, genitals, hands, feet), or any symptomatic disease regardless of extent 1, 2
• Critical caveat: Even patients with <5% BSA should receive systemic or phototherapy if they have symptomatic disease (pain, bleeding, itching) or significant quality of life impact 1, 2, 3

First-Line Topical Therapy for Mild Disease

Initial Treatment Phase (Weeks 1-8)

• Apply calcipotriene/betamethasone dipropionate combination product once daily for 4-8 weeks as the most effective first-line option 2, 3
• For trunk and extremities, use high-potency corticosteroids such as clobetasol propionate 0.05% or halobetasol propionate 0.05% 2, 3, 4
• Maximum vitamin D analogue use is 100g per week to avoid hypercalcemia 2, 3

Maintenance Therapy (After Initial Control)

• Transition to weekend-only high-potency corticosteroid application (twice daily on weekends) combined with weekday vitamin D analogue therapy (twice daily on weekdays) 2
• This rotational approach minimizes corticosteroid exposure while maintaining efficacy 2

Site-Specific Treatment Modifications

Facial and Intertriginous Psoriasis

• Use low-potency corticosteroids or calcitriol ointment to prevent skin atrophy 1, 2, 3
• Tacalcitol ointment or calcipotriene combined with hydrocortisone for 8 weeks is appropriate 2
• Never use high-potency corticosteroids on face or flexures due to high risk of atrophy and telangiectasia 2

Scalp Psoriasis

• Prescribe calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 1, 2, 3
• Clobetasol propionate topical solution is effective but has potential to depress plasma cortisol levels with repeated application 4

Nail Psoriasis

• Use calcipotriene combined with betamethasone dipropionate to reduce nail thickness, hyperkeratosis, and onycholysis 2
• Alternative: Tazarotene 0.1% cream under occlusion for 12 weeks shows comparable efficacy to clobetasol 2
• Important limitation: Topical agents have limited efficacy for severe nail disease due to poor nail matrix penetration 2

Combination Therapy Strategies

Enhancing Efficacy While Reducing Side Effects

• Combine tazarotene with medium- or high-potency corticosteroids for 8-16 weeks to increase efficacy while reducing local adverse events 2
• Apply tazarotene 0.1% gel once daily plus medium/high-potency corticosteroid for synergistic effect 2
• Apply tazarotene sparingly to lesions only, avoiding perilesional skin 2

Treatment for Moderate-to-Severe Psoriasis

Phototherapy as First-Line Systemic Treatment

• For patients with ≥5% BSA or inadequate response to topicals, initiate phototherapy (narrowband UVB or PUVA) as first-line systemic treatment 1, 3

Traditional Systemic Agents (Second-Line)

• Methotrexate: Inhibits dihydrofolate reductase with anti-inflammatory effects; requires regular monitoring of CBC, liver function tests, and serum creatinine 1, 3
• Cyclosporine: Requires monitoring of blood pressure and renal function 1, 3
• Acitretin: Decreases keratinocyte hyperproliferation and restores normal epidermal differentiation 1, 3

Biologic Therapies (Third-Line)

• TNF inhibitors, IL-17 inhibitors, IL-23 inhibitors, and IL-12/23 inhibitors are reserved for severe disease or inadequate response to traditional systemic agents 1, 3
• For psoriatic arthritis specifically, TNF inhibitors like adalimumab are effective for both skin and joint symptoms 1

Augmenting Biologic Therapy

• Adding ultra-high potency topical corticosteroid to biologic therapy for 12 weeks accelerates clearance and improves outcomes 3
• Clobetasol propionate spray 0.05% added to stable biologic regimens achieved clear or almost clear status in 81% of moderate disease, 79.5% of severe disease, and 58.8% of very severe disease 5

Critical Pitfalls to Avoid

Dangerous Drug Combinations and Practices

• Never combine salicylic acid with calcipotriene simultaneously—the acidic pH inactivates calcipotriene and eliminates its effectiveness 2, 3
• Avoid systemic corticosteroids in psoriasis—they cause disease flare during taper and may provoke pustular psoriasis 1, 3, 4
• Apply vitamin D analogues after phototherapy, not before, to avoid inactivation 1

Preventing Corticosteroid-Related Adverse Effects

• Limit continuous high-potency corticosteroid use to prevent skin atrophy, striae, telangiectasia, and HPA axis suppression 2, 3, 4
• Most frequent adverse events with clobetasol propionate include burning/stinging sensation (29 of 294 patients), scalp pustules, tingling, and folliculitis 4
• Regular clinical review is mandatory with no unsupervised repeat prescriptions for topical corticosteroids 1

Drugs That Worsen Psoriasis

• Avoid or use caution with: alcohol, beta-blockers, NSAIDs, lithium, chloroquine, and mepacrine, as these may precipitate or worsen psoriasis 1

Alternative and Adjunctive Options

• Coal tar, anthralin, and salicylic acid are older topical options with varying efficacy, useful for difficult refractory cases 1, 2, 6, 7
• Oral curcumin supplementation may benefit as adjunctive therapy 1
• Mindfulness meditation and stress reduction techniques can improve psoriasis severity in some patients 1