What are the treatment options for managing psoriasis?

Management of Psoriasis

Treatment Selection Based on Disease Severity

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

Defining Disease Severity

• Mild psoriasis requires all of the following: <5% body surface area involvement, asymptomatic (no pain, bleeding, or itching), and minimal impact on quality of life 1
• Moderate-to-severe psoriasis meets any of: ≥5% body surface area, symptomatic disease, more than minimal quality of life impact, inadequate response to topical therapy, or involvement of vulnerable areas (face, genitals, hands, feet) 1
• Critical caveat: Even patients with limited body surface area should be escalated to systemic therapy if they have symptomatic disease, as pain, bleeding, and itching indicate need for more aggressive treatment regardless of extent 1, 2

First-Line Topical Therapy Algorithm

Initial Treatment (Weeks 1-4)

Apply ultra-high potency corticosteroids (clobetasol propionate 0.05% or halobetasol propionate 0.05%) twice daily to thick plaques for maximum 2-4 weeks, achieving 58-92% efficacy in clearing lesions. 3, 2

• For body plaques: Use class 1 (ultra-high potency) or class 2 (high potency) corticosteroids twice daily 3
• For scalp psoriasis: Apply clobetasol propionate 0.05% shampoo twice weekly, leaving on scalp 5-10 minutes before rinsing 2
• Combination therapy is superior: Calcipotriene plus betamethasone dipropionate is more effective than either agent alone 1, 2

Location-Specific Modifications

Never use high-potency corticosteroids on the face, intertriginous areas, or genitals—use low-potency agents (class 5-7) or calcitriol ointment instead to avoid skin atrophy. 1, 2

• Face/flexures: Low-potency corticosteroids or tacrolimus 0.1% 3, 2
• Nails: Calcipotriene combined with betamethasone dipropionate, though efficacy is limited due to poor nail matrix penetration 1
• Thick, non-responding plaques: Consider intralesional triamcinolone acetonide up to 20 mg/mL every 3-4 weeks 2

Maintenance Phase (After Week 4)

Transition to weekend-only high-potency corticosteroid application with weekday vitamin D analogue therapy to minimize corticosteroid exposure while maintaining efficacy. 1, 2

• Apply high-potency corticosteroid twice daily on weekends only 1
• Apply vitamin D analogue (calcipotriene) twice daily on weekdays 1
• Maximum vitamin D analogue use: 100g per week to avoid hypercalcemia 1
• Taper frequency gradually rather than abrupt withdrawal to prevent rebound flare 2

Mandatory Safety Monitoring

Conduct clinical review every 4 weeks during active treatment with no unsupervised repeat prescriptions for high-potency agents. 3, 2

• Limit moderate-potency corticosteroid use to maximum 100g per month 3, 2
• Class 1-2 (very potent/potent) preparations require dermatological supervision 3, 2
• Plan annual periods using alternative non-corticosteroid treatments 3, 2
• Monitor for adverse effects: skin atrophy, striae, telangiectasia, HPA axis suppression 2, 4

Critical Pitfalls to Avoid

Never combine salicylic acid with calcipotriene simultaneously—the acidic pH inactivates calcipotriene and eliminates its effectiveness. 1

• Avoid systemic corticosteroids in psoriasis as they cause disease flare during taper 5
• Do not apply vitamin D analogues before phototherapy—apply after to avoid inactivation 5
• Avoid drugs that worsen psoriasis: lithium, chloroquine, mepacrine, beta-blockers, NSAIDs, and alcohol 3, 5

Escalation to Systemic Therapy

Refer to dermatology for systemic therapy when body surface area exceeds 5%, inadequate response to optimized topical therapy after 8 weeks, or signs of erythrodermic/pustular psoriasis develop. 2

Systemic Treatment Options

• For rapid response needed (erythrodermic psoriasis): Cyclosporine 3-5 mg/kg/day for 3-4 month interventional courses provides rapid onset of action 1
• Traditional systemic agents: Methotrexate, cyclosporine, acitretin for moderate-to-severe disease 1, 5
• Biologic agents: TNF inhibitors, IL-17 inhibitors, IL-23 inhibitors for severe disease or inadequate response to traditional agents 1, 5

Adjunctive Therapies

Evidence-Based Complementary Approaches

• Oral curcumin supplementation may benefit as adjunctive therapy 3, 5
• Stress reduction techniques (mindfulness meditation, cognitive behavioral therapy) can improve psoriasis severity 3, 5
• Gluten-free diet only for patients with confirmed celiac disease—trial period of 3 months if celiac antibodies positive 3

Therapies Without Sufficient Evidence

• Oral vitamin D supplementation does not improve disease activity at safe dosages 3
• Oral zinc supplementation does not improve PASI scores 3
• Cannabis and cannabinoids lack sufficient evidence to justify use 3

Special Considerations for Guttate Psoriasis

• Use lower concentrations of tar and dithranol for acute guttate psoriasis as erupting lesions are less tolerant 2
• Consider narrowband UVB phototherapy, which is especially helpful for guttate presentations 2
• Investigate and treat streptococcal infection with phenoxymethylpenicillin or erythromycin if persistent infection present 2