What are the treatment options for psoriasis?

Psoriasis Treatment

Treatment Selection Based on Disease Severity

For mild psoriasis (<5% body surface area), start with topical corticosteroids combined with vitamin D analogs as first-line therapy; for moderate-to-severe disease (≥5% BSA or involvement of vulnerable areas like face, genitals, hands, feet, or scalp), advance to phototherapy, and if inadequate, proceed to systemic agents (methotrexate, cyclosporine, acitretin) or biologics (IL-17, IL-23, or TNF inhibitors). 1, 2, 3

Mild Psoriasis Management (<5% BSA)

First-Line Topical Therapy

• Combination therapy with topical corticosteroids plus vitamin D analogs (calcipotriene/betamethasone dipropionate) provides superior efficacy and reduced irritation compared to monotherapy. 2, 3, 4

• Select corticosteroid potency based on location: ultra-high potency (Class I) for thick plaques on trunk and extremities; low-potency for face, genitals, and intertriginous areas to prevent skin atrophy. 3, 4

• Limit vitamin D analogs to maximum 100g per week to avoid hypercalcemia. 3

• Apply vitamin D analogs after phototherapy sessions to prevent inactivation. 2, 3

Alternative Topical Options

• Coal tar preparations and anthralin are effective alternatives with Level I-II evidence, though less commonly used due to cosmetic concerns. 4, 5

• Tazarotene (topical retinoid) can be used for localized plaques but may cause irritation. 5

Location-Specific Approaches

• Scalp psoriasis: Use calcipotriene foam or calcipotriene/betamethasone dipropionate gel for 4-12 weeks; consider excimer laser for resistant cases. 2, 3, 4

• Facial/intertriginous psoriasis: Use low-potency corticosteroids or topical calcitriol (less irritating than other vitamin D analogs). 2, 3, 4

Critical Monitoring Parameters

• Limit moderately potent corticosteroid preparations to no more than 100g per month. 3

• Require regular clinical review with no unsupervised repeat prescriptions. 3

• Plan periods of alternative treatment each year to prevent tachyphylaxis and minimize cumulative toxicity. 2

Moderate-to-Severe Psoriasis Management (≥5% BSA)

Second-Line: Phototherapy

• Narrowband UVB is first-line phototherapy for moderate-to-severe disease. 2, 3, 4

• PUVA (psoralen plus UVA) is an alternative for extensive disease or inadequate UVB response. 1, 2, 4

• 308-nm excimer laser targets localized resistant areas effectively. 3

• Avoid commercial sunbeds—they are rarely effective and increase skin aging and fragility risks. 4

Third-Line: Traditional Systemic Agents

Methotrexate 1, 2

• Dosing: Start 7.5-15mg weekly, increase gradually based on response
• Monitoring: Regular complete blood count, liver function tests, serum creatinine
• Advantages: Oral administration, low cost, effective for both skin and joint disease
• Contraindications: Absolutely contraindicated in pregnancy; avoid in significant liver disease, alcohol abuse, obesity (increased nonalcoholic steatohepatitis risk)

Cyclosporine 1, 5

• Duration limits: Maximum 1 year in US guidelines, 2 years in UK guidelines due to glomerulosclerosis risk
• Monitoring: Blood pressure, renal function, lipid profile
• Use for: Severe flares requiring rapid control

Acitretin 1, 5

• Preferred for: Erythrodermic/generalized pustular psoriasis, palmoplantar pustulosis
• Monitoring: Liver function, lipids
• Contraindications: Absolutely contraindicated in pregnancy (teratogenic)

Fourth-Line: Biologic Agents

IL-17 Inhibitors (secukinumab, ixekizumab, brodalumab) 6

• Highly effective for moderate-to-severe plaque psoriasis
• Rapid onset of action

IL-23 Inhibitors (guselkumab, tildrakizumab, risankizumab) 6

• Superior long-term efficacy and durability
• Less frequent dosing intervals

IL-12/23 Inhibitor (ustekinumab) 6

• Effective for both skin and joint manifestations

TNF Inhibitors (adalimumab, etanercept, infliximab) 1, 7

• Adalimumab dosing: 80mg initial dose, then 40mg every other week starting one week after initial dose 7
• Effective for psoriatic arthritis comorbidity
• Etanercept may be less effective in patients with high BMI 1

Psoriatic Arthritis Management

Mild joint symptoms: NSAIDs as first-line therapy. 1, 2, 4

Moderate-to-severe joint involvement: DMARDs (methotrexate, sulfasalazine, leflunomide) as first-line systemic therapy. 1, 2, 4

Inadequate DMARD response: TNF inhibitors (adalimumab, etanercept, infliximab) are highly effective for both skin and joint symptoms. 1, 2, 7

Enthesitis (severe, refractory): Consider TNF inhibitor after failure of therapies for mild/moderate disease. 1, 4

Dactylitis: Treat empirically with NSAIDs initially; advance to DMARDs or TNF inhibitors for persistent cases. 1

Combination Therapy Strategies

Enhancing Biologic Efficacy

• Adding ultra-high potency (Class I) topical corticosteroid to etanercept for 12 weeks improves outcomes (Level I evidence). 4

• Adding calcipotriene/betamethasone to adalimumab for 16 weeks accelerates plaque clearance. 4

• Adding topical calcipotriene to methotrexate enhances efficacy (Level I evidence). 4

• All topical corticosteroids can be safely combined with any biologic agent. 4, 8

Rotational Therapy

• Switch between treatment modalities every 1-2 years to minimize cumulative toxicity of individual treatments. 2, 4

Critical Pitfalls to Avoid

Systemic corticosteroids: Absolutely avoid as monotherapy—causes severe disease flare during or after taper. 1, 2, 3, 4

Long-term potent topical corticosteroids: Causes skin atrophy, striae, telangiectasia; use intermittent application for maintenance. 2, 3, 4

Drug-induced psoriasis exacerbation: Avoid or use cautiously: beta-blockers, NSAIDs, lithium, chloroquine, mepacrine, alcohol. 2, 3

Pregnancy considerations: All traditional systemic agents (methotrexate, acitretin, cyclosporine) are absolutely contraindicated in pregnancy. 4

Combination systemic agents: Multiple systemic immunosuppressants increase toxicity risk; methotrexate with biologics may cause additive immunosuppression. 1

Quality of Life Considerations

Symptomatic disease (pain, bleeding, itching) warrants systemic or phototherapy even with <5% BSA involvement. 1, 2, 3

Psychological distress and quality of life impact should drive treatment escalation regardless of physical extent. 1, 2, 3

Vulnerable area involvement (face, genitals, hands, feet, nails, scalp) justifies systemic therapy from onset despite limited BSA. 1, 2