Psoriasis Treatment Overview
Treatment Algorithm by Disease Severity
For mild psoriasis (<5% body surface area), initiate combination topical therapy with calcipotriene/betamethasone dipropionate once daily for 4-8 weeks, which achieves clear or almost clear skin in 48-74% of patients. 1, 2 For moderate-to-severe disease (≥5% BSA), advance to phototherapy or systemic agents as first-line treatment. 1, 2
Mild Psoriasis: Topical Therapy First-Line
Combination therapy with vitamin D analogs plus topical corticosteroids demonstrates superior efficacy compared to either agent alone and represents the gold standard for mild disease. 3, 4
- Apply calcipotriene/betamethasone dipropionate combination product once daily for initial control 1, 2
- High-potency corticosteroids (clobetasol propionate 0.05% or halobetasol propionate 0.05%) for trunk and extremities 5, 2
- Maximum vitamin D analog use: 100g per week to prevent hypercalcemia 6, 2
Biological rationale: Vitamin D analogs inhibit epidermal hyperproliferation and induce keratinocyte differentiation, while corticosteroids suppress pro-inflammatory cytokines—these complementary mechanisms produce synergistic effects. 4
Maintenance Strategy After Initial Control
Transition to weekend-only high-potency corticosteroid application with weekday vitamin D analog therapy to minimize corticosteroid exposure while maintaining efficacy. 2
- High-potency topical corticosteroid twice daily on weekends only 2
- Vitamin D analog twice daily on weekdays 2
- This rotational approach reduces risk of skin atrophy, striae, and HPA axis suppression 2
Site-Specific Modifications
For facial and intertriginous psoriasis, use low-potency corticosteroids or calcitriol ointment exclusively—never high-potency agents—to prevent skin atrophy. 6, 2
- Tacrolimus may be considered first-line for intertriginous psoriasis 6
- Calcitriol ointment is less irritating than calcipotriene for sensitive areas 6
For scalp psoriasis, use calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks. 1, 5
For nail psoriasis, apply calcipotriene combined with betamethasone dipropionate, though efficacy is limited due to poor nail matrix penetration. 5, 2
- Tazarotene 0.1% cream under occlusion for 12 weeks shows comparable efficacy to clobetasol 2
- Severe nail disease typically requires systemic therapy 2
Corticosteroid-Sparing Strategies
Combine tazarotene with medium- or high-potency corticosteroids for 8-16 weeks to increase efficacy while reducing local adverse events and prolonging remission. 6, 2
- Apply tazarotene 0.1% gel once daily plus medium/high-potency corticosteroid 2
- Apply tazarotene sparingly to lesions only, avoiding perilesional skin to minimize irritation 6, 2
Moderate-to-Severe Psoriasis: Systemic Therapy
For patients with ≥5% BSA or inadequate response to topicals, initiate phototherapy (narrowband UVB) as first-line systemic treatment. 1, 2
Traditional Systemic Agents (Second-Line)
Methotrexate: Inhibits dihydrofolate reductase and increases endogenous adenosine with anti-inflammatory effects 6, 2
- Requires regular monitoring: complete blood count, liver function tests, serum creatinine 2
Cyclosporine: 3-5 mg/kg/day for rapid onset, particularly effective for erythrodermic psoriasis requiring rapid response 5
- Use in short 3-4 month "interventional" courses 5
- Monitor blood pressure, renal function, and lipid profile 2
Acitretin: Decreases keratinocyte hyperproliferation and restores normal epidermal differentiation 6, 5
- Cannot be used in women of childbearing potential due to teratogenicity 5
- Slower onset compared to cyclosporine 5
Biologic Therapies (Third-Line)
For severe disease or failure of traditional systemic agents, advance to biologic therapy with TNF inhibitors, IL-17 inhibitors, IL-23 inhibitors, or IL-12/23 inhibitors. 1, 2
- Adalimumab (TNF inhibitor): 80 mg initial dose, followed by 40 mg every other week starting one week after initial dose 7
- Effective for both skin and joint symptoms in psoriatic arthritis 1
Adding ultra-high potency topical corticosteroid to biologic therapy for 12 weeks accelerates clearance and improves outcomes. 2, 8
Special Populations
Pediatric Psoriasis
For children with localized psoriasis, ultra-high-potency topical corticosteroids as monotherapy are effective for short-term treatment. 2
Dual topical therapy with high-potency steroid and vitamin D analog is standard practice. 2
Psoriatic Arthritis
For mild joint symptoms, initiate NSAIDs; for moderate-to-severe joint involvement, use DMARDs; for inadequate response to at least one DMARD, advance to TNF inhibitors. 1
Alternative Medicine Approaches
Oral curcumin supplementation may benefit as adjunctive therapy, though it has low toxicity but poor bioavailability. 6
Fish oil/omega-3 fatty acid oral supplementation may augment effects of topical, oral-systemic, and phototherapy for chronic plaque psoriasis. 6
- Select supplements free of mercury, dioxin, and polychlorinated biphenyls 6
Oral vitamin D supplementation is NOT recommended for treatment of psoriasis—use topical vitamin D agents instead. 6
Critical Pitfalls to Avoid
NEVER combine salicylic acid with calcipotriene simultaneously—the acidic pH inactivates calcipotriene and eliminates its effectiveness. 2
NEVER use systemic corticosteroids in psoriasis—they cause disease flare during taper. 1, 2
NEVER use high-potency corticosteroids on face or flexures—use low-potency agents or tacrolimus instead. 2
Limit continuous high-potency corticosteroid use to prevent skin atrophy, striae, telangiectasia, and HPA axis suppression. 2
Apply vitamin D analogs AFTER phototherapy to avoid inactivation. 1
Avoid combining multiple systemic agents simultaneously due to increased toxicity risk. 1
Quality of Life Considerations
Symptomatic psoriasis (pain, bleeding, itching) requires systemic or phototherapy regardless of body surface area involvement. 1, 5, 2
Quality of life impact should drive treatment intensity, not just physical extent of disease. 1, 2