What are the treatment options for psoriasis?

Treatment for Psoriasis

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 status in 48-74% of patients. 1, 2, 3

Mild Psoriasis: Topical Therapy Algorithm

First-line approach:

• Apply calcipotriene/betamethasone dipropionate combination product once daily for 4-8 weeks 1, 2, 3
• For trunk and extremities, use high-potency corticosteroids (clobetasol propionate 0.05% or halobetasol propionate 0.05%) 2, 3
• Maximum vitamin D analogue use: 100g per week to avoid hypercalcemia 2, 3

Maintenance strategy after initial control:

• Transition to weekend-only high-potency corticosteroid application (twice daily on weekends only) 2
• Apply vitamin D analogue twice daily on weekdays 2
• This minimizes corticosteroid exposure while maintaining efficacy 2

Site-Specific Modifications

Facial and intertriginous psoriasis:

• Use low-potency corticosteroids or calcitriol ointment to prevent skin atrophy 1, 2, 3
• Never use high-potency corticosteroids on face or flexures 2

Scalp psoriasis:

• Use calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 1, 2, 3

Nail psoriasis:

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

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

For moderate-to-severe psoriasis, initiate phototherapy (narrowband UVB or PUVA) as first-line systemic treatment. 1, 3

Phototherapy Options

• Narrowband UVB phototherapy 1
• PUVA (psoralen plus UVA) 1

Traditional Systemic Agents (Second-Line)

Methotrexate:

• Inhibits dihydrofolate reductase and increases endogenous adenosine with anti-inflammatory effects 3
• Requires regular monitoring of complete blood count, liver function tests, and serum creatinine 3
• Consider subcutaneous administration to bypass the liver for more predictable absorption 4

Cyclosporine:

• Dose: 3-5 mg/kg/day for rapid onset of action 4
• Particularly effective for erythrodermic psoriasis requiring rapid response 4
• Requires monitoring of blood pressure, renal function, and lipid profile 3
• Generally use short 3-4 month "interventional" courses 4

Acitretin:

• Decreases keratinocyte hyperproliferation and restores normal epidermal differentiation 3
• Cannot be used in women of childbearing potential due to teratogenicity 4
• Has slower onset of action compared to cyclosporine 4

Biologic Therapies (Third-Line)

For severe disease or inadequate response to traditional systemic agents:

• TNF inhibitors (e.g., adalimumab 40 mg every other week subcutaneously) 1, 5
• IL-17 inhibitors 1, 3
• IL-23 inhibitors 1, 3
• IL-12/23 inhibitors 1, 3

Adalimumab dosing for psoriasis:

• 80 mg initial dose, followed by 40 mg every other week starting one week after initial dose 5

Special Considerations

Psoriatic Arthritis

• NSAIDs for mild joint symptoms 1
• DMARDs for moderate-to-severe joint involvement 1
• TNF inhibitors (like adalimumab) for inadequate response to at least one DMARD—effective for both skin and joint symptoms 1, 5

Erythrodermic Psoriasis

Requires distinct approach favoring rapid-acting therapies:

• Oral cyclosporine 3-5 mg/kg/day is the logical choice for systemically ill patients due to rapid and impressive onset of action 4
• Mid-potency topical corticosteroids and emollients under occlusion may help restore barrier function but systemic treatment is inevitably necessary 4
• Base therapy on short-term efficacy rather than long-term considerations; transition to maintenance therapy after acute illness improves 4

Pediatric Psoriasis

Juvenile Idiopathic Arthritis or Pediatric Uveitis (2 years and older):

• 10-15 kg: 10 mg every other week 5
• 15-30 kg: 20 mg every other week 5
• ≥30 kg: 40 mg every other week 5

Hidradenitis Suppurativa (12 years and older):

• 30-60 kg: Day 1: 80 mg, then 40 mg every other week starting Day 8 5
• ≥60 kg: Day 1: 160 mg, Day 15: 80 mg, then 40 mg weekly or 80 mg every other week starting Day 29 5

Combination Strategies

Enhance efficacy with combination approaches:

• Tazarotene 0.1% gel once daily plus medium/high-potency corticosteroid for 8-16 weeks increases efficacy while reducing local adverse events and prolonging remission 2
• Adding ultra-high potency topical corticosteroid to biologic therapy (e.g., etanercept) for 12 weeks accelerates clearance and improves outcomes 3
• Apply tazarotene sparingly to lesions only, avoiding perilesional skin 2

Critical Pitfalls to Avoid

Never combine salicylic acid with calcipotriene simultaneously—the acidic pH inactivates calcipotriene and eliminates its effectiveness. 2, 3

Additional critical warnings:

• Avoid systemic corticosteroids in psoriasis as they cause disease flare during taper 1, 3
• Limit continuous high-potency corticosteroid use to prevent skin atrophy, striae, telangiectasia, and HPA axis suppression 2, 3
• Apply vitamin D analogues after phototherapy to avoid inactivation 1
• Screen for latent tuberculosis before starting TNF inhibitors; if positive, start TB treatment prior to initiating biologic therapy 5
• Monitor all patients on TNF inhibitors for active TB during treatment, even if initial latent TB test is negative 5

When to Escalate Treatment

Consider systemic or phototherapy regardless of body surface area involvement if:

• Patient has symptomatic psoriasis (pain, bleeding, itching) 1, 2, 3
• More than minimal impact on quality of life 2
• Inadequate response to localized therapy 2
• Varying degrees of incapacity and disability 2