What are the treatment options for psoriasis?

Treatment Options for Psoriasis

For mild psoriasis (<5% body surface area), start with combination calcipotriene/betamethasone dipropionate once daily for 4-8 weeks, which achieves clear or almost clear status in 48-74% of patients; for moderate-to-severe disease (≥5% BSA or symptomatic), escalate to phototherapy, traditional systemic agents (methotrexate, cyclosporine, acitretin), or biologic therapies based on disease severity and comorbidities. 1, 2

Disease Severity Classification

• Mild psoriasis is defined as <5% body surface area involvement with minimal symptoms 1, 2, 3
• Moderate-to-severe psoriasis is ≥5% BSA or involvement of vulnerable areas (face, genitals, hands, feet) 2, 3
• Symptomatic psoriasis (pain, bleeding, itching) warrants systemic or phototherapy regardless of BSA involvement 1, 2, 3
• Quality of life impact should drive treatment decisions even when physical extent is limited 2, 3

First-Line Treatment for Mild Psoriasis

Optimal Topical Regimen

• Start with calcipotriene/betamethasone dipropionate combination product once daily for 4-8 weeks as the most effective first-line approach 1
• High-potency topical corticosteroids (clobetasol propionate 0.05%, halobetasol propionate 0.05%) are recommended alternatives 1
• Vitamin D analogues (calcipotriene, calcitriol) can be used continuously for up to 52 weeks and are particularly effective for scalp psoriasis 1

Maintenance Strategy After Initial Control

• Transition to weekend-only high-potency corticosteroid application (twice daily on weekends) with weekday vitamin D analogue therapy (twice daily on weekdays) to minimize corticosteroid exposure while maintaining efficacy 1
• This rotational approach reduces risk of skin atrophy, striae, and HPA axis suppression 1
• Maximum vitamin D analogue use is 100g per week to avoid hypercalcemia 1

Site-Specific Treatment Modifications

Scalp Psoriasis

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

Facial and Intertriginous Psoriasis

• Use low-potency corticosteroids or calcitriol ointment to avoid skin atrophy 1, 2, 3
• Tacalcitol ointment or calcipotriene combined with hydrocortisone for 8 weeks is effective 1
• Never use high-potency corticosteroids on face or flexures 1

Nail Psoriasis

• Calcipotriene combined with betamethasone dipropionate reduces nail thickness, hyperkeratosis, and onycholysis 1
• Tazarotene 0.1% cream under occlusion for 12 weeks shows comparable efficacy to clobetasol 1
• Note that topical agents have limited efficacy for severe nail disease due to poor nail matrix penetration 1

Treatment for Moderate-to-Severe Psoriasis

First-Line: Phototherapy

• Narrowband UVB or PUVA phototherapy is recommended as first-line treatment for moderate-to-severe psoriasis 2, 3
• Apply vitamin D analogues after phototherapy to avoid inactivation 2

Second-Line: Traditional Systemic Agents

Cyclosporine:

• Use 3-5 mg/kg/day for rapid onset of action, particularly effective for erythrodermic psoriasis requiring rapid response 1
• Limit to short 3-4 month "interventional" courses 1
• Requires regular monitoring of blood pressure, renal function, and lipid profile 3

Methotrexate:

• Effective for moderate-to-severe psoriasis and psoriatic arthritis 1, 2, 3, 4
• Requires regular monitoring of full blood count, liver function tests, and serum creatinine 3, 4
• Adverse reactions include elevated liver function tests (15%), nausea/vomiting (10%), stomatitis, and thrombocytopenia 4

Acitretin:

• Decreases keratinocyte hyperproliferation and restores normal epidermal differentiation 1
• Cannot be used in women of childbearing potential due to teratogenicity 1
• Has slower onset of action compared to cyclosporine 1

Third-Line: Biologic Therapies

• TNF inhibitors (etanercept, adalimumab), IL-17 inhibitors, IL-23 inhibitors, and IL-12/23 inhibitors are recommended for moderate-to-severe psoriasis 1, 2, 3
• Etanercept at 50 mg twice weekly for 3 months achieved PASI 75 in 47% of patients 5
• Adding ultra-high potency topical corticosteroids to biologic therapy enhances efficacy 3, 6

Combination Strategies to Enhance Efficacy

• Combine tazarotene with medium- or high-potency corticosteroids for 8-16 weeks to increase efficacy while reducing local adverse events 1
• Adding calcipotriene/betamethasone to adalimumab accelerates clearance of psoriatic plaques 3
• Adding topical calcipotriene to methotrexate therapy improves outcomes 3

Treatment for Psoriatic Arthritis

• NSAIDs for mild joint symptoms 2, 3
• DMARDs (methotrexate, sulfasalazine, leflunomide) for moderate-to-severe joint involvement 2, 3
• TNF inhibitors for inadequate response to at least one DMARD 2, 3
• TNF inhibitors like adalimumab are effective for both skin and joint symptoms 2

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—they can cause disease flare during taper 2, 3
• Limit continuous high-potency corticosteroid use to prevent skin atrophy, striae, telangiectasia, and HPA axis suppression 1, 2, 3
• All commonly used systemic agents are absolutely contraindicated in pregnancy 3
• Apply tazarotene sparingly to lesions only, avoiding perilesional skin 1

Special Considerations for Erythrodermic Psoriasis

• Oral cyclosporine 3-5 mg/kg/day is the logical choice for systemically ill patients due to rapid and impressive onset of action 1
• Mid-potency topical corticosteroids and emollients under occlusion may help restore barrier function, but systemic treatment is inevitably necessary 1
• Base therapy on short-term efficacy rather than long-term considerations, and transition to maintenance therapy after acute illness improves 1