What are the treatment options for psoriasis?

Psoriasis Treatment Options

Treatment Selection Based on Disease Severity

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 skin in 48-74% of patients. 1

For moderate-to-severe psoriasis (≥5% BSA), escalate to phototherapy as first-line, followed by traditional systemic agents (methotrexate, cyclosporine, acitretin) as second-line, and biologic agents (IL-17, IL-23, IL-12/23, or TNF inhibitors) as third-line options. 2, 3

Critical Exception to BSA-Based Treatment

• Even with limited BSA involvement, escalate to systemic therapy or phototherapy if the patient experiences symptomatic disease (pain, bleeding, itching) or significant quality of life impairment. 2, 1, 3

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Topical Therapy Algorithm for Mild Disease

Initial Treatment Phase (Weeks 1-8)

• Apply calcipotriene/betamethasone dipropionate combination product once daily for 4-8 weeks as first-line therapy. 1
• For scalp involvement, use calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks. 2, 1
• For facial or intertriginous areas, use low-potency corticosteroids or calcitriol ointment to prevent skin atrophy—never use high-potency agents in these locations. 1, 3

Maintenance Phase (After Initial Control)

• Transition to weekend-only high-potency corticosteroid application (twice daily on weekends) combined with vitamin D analogue twice daily on weekdays. 1, 4
• This regimen minimizes corticosteroid exposure while maintaining efficacy and reducing long-term adverse effects. 1
• Limit vitamin D analogue use to maximum 100g per week to avoid hypercalcemia. 1

Alternative Topical Options

• Tazarotene 0.1% gel once daily combined with medium/high-potency corticosteroid for 8-16 weeks increases efficacy while reducing irritation and prolonging remission. 1
• Coal tar, anthralin, and salicylic acid remain options for refractory disease, though less commonly used. 2, 5

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Site-Specific Treatment Modifications

Nail Psoriasis

• Use calcipotriene combined with betamethasone dipropionate to reduce nail thickness, hyperkeratosis, and onycholysis. 1
• Alternatively, apply tazarotene 0.1% cream under occlusion for 12 weeks. 1
• Note that topical agents have limited efficacy for severe nail disease due to poor nail matrix penetration. 1

Scalp Psoriasis

• Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks is recommended. 2, 1
• Formulations include solutions, foams, and shampoos containing topical corticosteroids, vitamin D analogues, salicylic acid, coal tar, or anthralin. 5

Palmoplantar Psoriasis

• Use high-potency topical corticosteroids for thick plaques. 5
• Vitamin D analogues alone or in combination with topical corticosteroids are effective. 5

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Phototherapy for Moderate-to-Severe Disease

• Narrowband UVB or PUVA phototherapy is first-line treatment for moderate-to-severe psoriasis (≥5% BSA). 2, 3
• Apply vitamin D analogues after phototherapy sessions to avoid inactivation by UV light. 2
• Commercial sunbeds are ineffective and should be avoided due to premature skin aging and increased skin fragility. 3

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Systemic Non-Biologic Therapies (Second-Line)

• Methotrexate, cyclosporine, and acitretin are traditional systemic agents for moderate-to-severe psoriasis. 2, 1, 3
• All systemic agents are absolutely contraindicated in pregnancy. 3

Monitoring Requirements

• For methotrexate: Monitor complete blood count, liver function tests, and serum creatinine regularly. 3
• For cyclosporine: Monitor blood pressure, renal function, and lipid profile regularly. 3

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Biologic Therapies (Third-Line)

• IL-17 inhibitors, IL-23 inhibitors, IL-12/23 inhibitors, and TNF inhibitors are recommended for moderate-to-severe psoriasis when traditional systemic agents are inadequate. 2, 1, 3
• Adding ultra-high potency (Class I) topical corticosteroid to biologic therapy for 12 weeks enhances clearance rates. 3, 6
• In one study, 81% of patients with moderate disease and 79.5% with severe disease achieved clear or almost clear skin when clobetasol propionate spray 0.05% was added to stable biologic therapy. 6

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Treatment for Psoriatic Arthritis

Mild Joint Symptoms

• Start with NSAIDs for symptomatic relief. 2, 3

Moderate-to-Severe Joint Involvement

• Use DMARDs (methotrexate, sulfasalazine, leflunomide) as first-line systemic therapy. 2, 3

Inadequate Response to DMARDs

• Escalate to TNF inhibitors, which are effective for both skin and joint symptoms. 2, 3
• For severe enthesitis failing other therapies, consider TNF inhibitors. 3

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Critical Pitfalls to Avoid

• Never use systemic corticosteroids for psoriasis—they cause disease flare during taper and may provoke pustular psoriasis. 2, 3
• Never combine salicylic acid with calcipotriene simultaneously—the acidic pH inactivates calcipotriene completely. 1
• Limit continuous high-potency corticosteroid use to prevent skin atrophy, striae, telangiectasia, and HPA axis suppression. 2, 1, 7
• Do not use high-potency corticosteroids on face or flexures—use low-potency agents instead. 1, 3
• Avoid combining multiple systemic agents due to increased toxicity risk. 2
• Drugs that may precipitate or worsen psoriasis include alcohol, beta-blockers, NSAIDs, lithium, chloroquine, and mepacrine. 2

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Adjunctive Strategies

• Maintain ideal body weight, avoid tobacco products, limit alcohol, and practice stress reduction techniques to improve disease management. 8
• Oral curcumin supplementation and mindfulness meditation may benefit as adjunctive therapy. 2
• Gluten-free diet should only be considered for patients with diagnosed celiac disease. 2