What is the most effective treatment for psoriasis?

Treatment of Psoriasis

For mild psoriasis (<5% body surface area), use combination therapy with topical corticosteroids (class 2-5) plus vitamin D analogs (calcipotriene) for maximum 4 weeks, then transition to weekend-only corticosteroid application with weekday vitamin D analog use for maintenance. 1, 2, 3

Disease Severity Classification and Treatment Selection

Mild psoriasis is defined as <3-5% body surface area, while moderate-to-severe is ≥5% BSA or involvement of high-impact areas (palms/soles, face, genitals, scalp) regardless of total BSA. 1, 2 Quality of life impact and symptoms (pain, bleeding, itching) should trigger escalation to systemic therapy even with limited BSA involvement. 2

Treatment Algorithm for Mild Psoriasis

First-Line Topical Therapy

• Combination therapy with topical corticosteroids plus vitamin D analogs is superior to monotherapy, providing synergistic effects with enhanced efficacy and reduced irritation. 1, 2, 3, 4

• Apply moderate to high potency corticosteroids (class 2-5) for maximum 4 weeks to plaques not affecting intertriginous areas. 1, 3

• For maintenance therapy, transition to weekend-only corticosteroid application while using vitamin D analogs on weekdays to prevent tachyphylaxis and skin atrophy. 1, 3

• For scalp psoriasis, use calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks. 2

• For facial and intertriginous psoriasis, use low-potency corticosteroids or topical calcineurin inhibitors (tacrolimus 0.1%) to avoid skin atrophy. 1, 2, 3

Alternative Topical Agents

• Tazarotene (topical retinoid) combined with moderate to high potency corticosteroids reduces irritation while enhancing efficacy. 3

• Coal tar preparations can be used as alternative treatment, starting with 0.5-1.0% concentrations and gradually increasing to 10%. 3, 5

Treatment Algorithm for Moderate-to-Severe Psoriasis

Phototherapy (Second-Line)

• Narrowband UVB or PUVA phototherapy is first-line treatment for moderate-to-severe psoriasis (≥5% BSA) when topical therapy fails. 2, 6

Traditional Systemic Agents (Third-Line)

• Methotrexate is the preferred first-line systemic option, starting at 15 mg weekly, maximum 25-30 mg weekly, with regular monitoring of complete blood count, liver function, and serum creatinine. 1, 2

• Cyclosporine at 2.5-5 mg/kg daily is effective but limited to 1 year use in the US (2 years in UK) due to glomerulosclerosis risk, requiring blood pressure and renal function monitoring. 1, 2

• Acitretin 25-50 mg daily is first-line for pustular and erythrodermic psoriasis. 1, 2

Biologic Therapy (Fourth-Line)

• TNF inhibitors (adalimumab, etanercept, infliximab) are superior to conventional synthetic DMARDs as first-line biologic therapy, particularly in early disease. 1, 7

• IL-12/23 inhibitors (ustekinumab) show 67% clearance in palmoplantar pustular psoriasis at 90mg dose. 1

• IL-17 inhibitors and IL-23 inhibitors are recommended as third-line treatment for moderate-to-severe psoriasis. 2

• Adalimumab (HUMIRA) is FDA-approved for moderate to severe chronic plaque psoriasis in adults who are candidates for systemic therapy or phototherapy when other systemic therapies are medically less appropriate. 7

Combination Strategies for Enhanced Efficacy

• Adding ultra-high potency (Class I) topical corticosteroids to standard dose etanercept for 12 weeks improves outcomes in moderate to severe psoriasis. 2

• Adding calcipotriene/betamethasone to standard dose adalimumab for 16 weeks accelerates clearance of psoriatic plaques. 2

• Adding topical calcipotriene to standard dose methotrexate enhances efficacy in moderate to severe psoriasis. 2

Special Clinical Scenarios

Pustular Psoriasis

• Acitretin 25-50 mg daily is first-line treatment, with ustekinumab as an alternative for moderate-to-severe cases. 1

Erythrodermic Psoriasis

• Cyclosporine, infliximab, or acitretin are recommended treatment options. 1

Psoriatic Arthritis

• NSAIDs for mild joint symptoms. 2
• DMARDs (methotrexate, sulfasalazine, leflunomide) for moderate-to-severe joint involvement. 2
• TNF inhibitors for inadequate response to at least one DMARD. 2

Critical Medications to AVOID

• NEVER use systemic corticosteroids as monotherapy in psoriasis—they cause disease flare during or after taper and can precipitate pustular or erythrodermic psoriasis. 1, 2, 3

• Lithium, chloroquine, and mepacrine are associated with severe, potentially fatal psoriasis deterioration and should be avoided. 1, 3

• Avoid salicylic acid with calcipotriol as the acidic pH inactivates calcipotriol and reduces effectiveness. 3

Common Pitfalls and Monitoring

• Perceived "tachyphylaxis" to topical corticosteroids is often due to poor patient adherence rather than true receptor down-regulation. 3

• Long-term use of potent topical corticosteroids causes skin atrophy, striae, and telangiectasia—limit to 4 weeks then transition to maintenance regimen. 1, 2

• All commonly used systemic agents are absolutely contraindicated in pregnancy. 2

• Commercial sunbeds are rarely effective for psoriasis and may cause premature skin aging and increased skin fragility. 2