What are the current treatment options for psoriasis?

Current Treatment for Psoriasis

For mild psoriasis with limited body surface area, start with calcipotriene/betamethasone dipropionate combination topical therapy once daily for 4-8 weeks, which achieves clear or almost clear skin in 48-74% of patients; for moderate-to-severe disease or symptomatic psoriasis regardless of extent, initiate systemic therapy with biologics (IL-17, IL-23, or IL-12/23 inhibitors preferred over TNF inhibitors for superior skin efficacy) or phototherapy. 1, 2

Disease Severity Classification and Treatment Selection

Treatment intensity must be driven by symptoms and quality of life impact, not just body surface area percentage. 2

Mild psoriasis criteria:

• Less than 5% body surface area involvement 3
• Generally asymptomatic (no pain, bleeding, or itching) 3
• Candidates for topical therapy alone 3

Moderate-to-severe psoriasis requires systemic or phototherapy if:

• Symptomatic disease present 2, 3
• More than minimal quality of life impact 3
• Inadequate response to topical therapy 3
• ≥5% body surface area involvement 2

First-Line Topical Therapy for Mild Psoriasis

Apply calcipotriene/betamethasone dipropionate combination product once daily for 4-8 weeks as the most effective topical approach. 2, 4

For trunk and extremities, use high-potency corticosteroids such as clobetasol propionate 0.05% or halobetasol propionate 0.05%. 2, 4

Site-specific modifications:

• Facial/intertriginous areas: Use low-potency corticosteroids or calcitriol ointment to prevent skin atrophy 2, 4
• Scalp: Use calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 3, 4
• Nails: Apply calcipotriene combined with betamethasone dipropionate, though efficacy is limited due to poor nail matrix penetration 1, 3

Critical dosing limits:

• Maximum vitamin D analogue use: 100 g per week to avoid hypercalcemia 2, 4

Maintenance Therapy Strategy

After achieving initial control, transition to weekend-only high-potency corticosteroid application with weekday vitamin D analogue therapy to minimize corticosteroid exposure while maintaining efficacy. 2

Specific regimen:

• Apply high-potency topical corticosteroid twice daily on weekends only 2
• Apply vitamin D analogue twice daily on weekdays 2

Combination Strategies to Enhance Efficacy

Combining tazarotene with medium- or high-potency corticosteroids for 8-16 weeks increases efficacy while reducing local adverse events and prolonging remission. 2, 4

When using systemic biologics, adding ultra-high potency topical corticosteroid for 12 weeks accelerates clearance and improves outcomes. 2, 4

Phototherapy for Moderate-to-Severe Psoriasis

Narrowband UVB phototherapy is first-line systemic treatment for patients with ≥5% body surface area or inadequate response to topicals. 2, 4

Additional phototherapy options include oral PUVA, bath PUVA with or without acitretin, and 308-nm excimer laser for localized resistant areas such as scalp and skin folds. 2, 3

Phototherapy is particularly efficacious for psoriasis affecting the trunk and extremities. 1

Traditional Systemic Agents for Moderate-to-Severe Psoriasis

Methotrexate:

• Inhibits dihydrofolate reductase and increases endogenous adenosine with anti-inflammatory effects 2, 4
• Requires regular monitoring of complete blood count, liver function tests, and serum creatinine 2, 4
• FDA-approved since 1972 for psoriasis treatment 3

Cyclosporine:

• Dose: 3-5 mg/kg/day in short 3-4 month "interventional" courses 2, 4
• Particularly effective for erythrodermic psoriasis requiring rapid response 2
• Requires monitoring of blood pressure, renal function, and lipid profile 4

Acitretin:

• Decreases keratinocyte hyperproliferation and restores normal epidermal differentiation 2, 3
• Conditionally recommended for psoriasis in patients with psoriatic arthritis due to limited efficacy as monotherapy for plaque psoriasis 1
• Can be efficacious for pustular psoriasis 1
• Cannot be used in women of childbearing potential due to teratogenicity 2, 3

Other oral therapies:

• PDE4 inhibitors and JAK inhibitors are strongly recommended for widespread psoriasis or disease unresponsive to topicals 1

Biologic Therapies for Moderate-to-Severe Psoriasis

Biologics are an option for first-line treatment of moderate-to-severe plaque psoriasis due to their efficacy and acceptable safety profiles. 2

Efficacy hierarchy for skin involvement: Newer mode of action drugs (IL-17, IL-12/23, and IL-23 inhibitors) show higher efficacy for skin involvement than TNF inhibitors in head-to-head studies. 1

Strongly recommended biologic classes:

• IL-23 inhibitors: Guselkumab, tildrakizumab, risankizumab, mirikizumab (newer generation with favorable efficacy profiles) 2
• IL-17 inhibitors 1
• IL-12/23 inhibitors 1
• TNF inhibitors 1

FDA-approved TNF inhibitor example (Adalimumab/HUMIRA):

• Indicated 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 5
• Dosing: 80 mg initial dose, followed by 40 mg every other week starting one week after initial dose 5
• Black box warnings: Increased risk of serious infections (including tuberculosis, bacterial sepsis, invasive fungal infections) and malignancies (including lymphoma) 5
• Perform test for latent TB before starting; if positive, treat TB prior to initiating therapy 5

Selection criteria between biologics:

• Results of head-to-head studies in psoriasis populations 1
• Presence of comorbidities 1
• Disease activity in other psoriatic arthritis domains if applicable 1

Agents with limited evidence for skin disease:

• Leflunomide and sulfasalazine (csDMARDs) have limited evidence for efficacy in cutaneous psoriasis 1
• CTLA4-Ig (abatacept) has limited evidence for efficacy in skin disease 1

Critical Pitfalls to Avoid

Never combine salicylic acid with calcipotriene simultaneously—the acidic pH inactivates calcipotriene and eliminates its effectiveness. 2, 4

Avoid systemic corticosteroids in psoriasis as they cause disease flare during taper. 4

Do not use high-potency corticosteroids on face or flexures—use low-potency agents or tacrolimus instead to prevent skin atrophy. 2

Limit continuous high-potency corticosteroid use to prevent skin atrophy, striae, telangiectasia, and HPA axis suppression. 2, 4

Avoid IL-17 inhibitors (secukinumab and brodalumab) in patients with known Crohn's disease as they exacerbated disease in RCTs. 1

Drugs that worsen psoriasis:

• Avoid or use with extreme caution: lithium, chloroquine, and mepacrine (may cause severe deterioration) 2
• May precipitate or worsen psoriasis: beta-blockers, NSAIDs, and alcohol 2

Special Considerations for Comorbid Inflammatory Bowel Disease

For patients with concurrent Crohn's disease or ulcerative colitis, TNF inhibitors (excluding etanercept) and IL-12/23 inhibitors have demonstrated efficacy in high-quality RCTs. 1

Methotrexate shows efficacy in Crohn's disease and ulcerative colitis based on RCT data. 1

Etanercept did not show efficacy for inflammatory bowel disease. 1