What are the treatment options for managing psoriasis?

Psoriasis Management

Treatment Algorithm Based on Disease Severity

For mild psoriasis (<5% body surface area), initiate treatment with high-potency topical corticosteroids (clobetasol propionate 0.05% or betamethasone dipropionate 0.05%) combined with calcipotriol (vitamin D analog) for 2-4 weeks, as this dual therapy achieves superior efficacy (58-92% clearance rates) compared to monotherapy. 1

Mild Disease: Topical Therapy First-Line

Initial regimen:

• Apply high-potency topical corticosteroids (class 1-2) twice daily to thick plaques for maximum 2-4 weeks 1
• Combine with calcipotriol for synergistic effect—either as separate products or fixed-combination formulations 1, 2
• For scalp involvement, use clobetasol propionate 0.05% shampoo twice weekly, leaving on scalp 5-10 minutes before rinsing 1

Location-specific modifications:

• Use low-potency corticosteroids (class 5-7) or topical calcineurin inhibitors (tacrolimus 0.1%) on face, intertriginous areas, genitals, and forearms where atrophy risk is highest 1, 2
• For body plaques, add tazarotene (topical retinoid) combined with moderate-to-high potency corticosteroids to reduce irritation while enhancing efficacy 1, 2
• For thick, non-responding plaques, consider intralesional triamcinolone acetonide up to 20 mg/mL every 3-4 weeks 1

Maintenance phase transition:

• After achieving control at 2-4 weeks, transition to weekend-only corticosteroid application while using vitamin D analogs on weekdays 1, 2
• Taper frequency gradually rather than abrupt withdrawal to prevent rebound flare 1
• Plan annual periods employing alternative non-corticosteroid treatments to prevent continuous high-potency steroid exposure 1

Alternative topical agents when first-line fails:

• Coal tar: Start with 0.5-1.0% crude coal tar in petroleum jelly, increase every few days to maximum 10% 3
• Dithranol: Start at 0.1-0.25% concentration, increase in doubling concentrations as tolerated 3
• These alternatives are particularly useful for patients who fail to respond to one topical agent, as they may respond to another 3, 2

Mandatory safety monitoring for topical corticosteroids:

• Conduct regular clinical review every 4 weeks during active treatment with no unsupervised repeat prescriptions for high-potency agents 1
• Limit moderate-potency corticosteroid use to maximum 100g per month 1
• Require dermatological supervision for class 1-2 (very potent/potent) preparations 1

Moderate-to-Severe Disease: Systemic Therapy Indications

Escalate to systemic therapy when: 1

• Body surface area involvement exceeds 5%
• Inadequate response to optimized topical therapy after 8 weeks
• Scalp tenderness persists despite adequate anti-inflammatory treatment
• Signs of erythrodermic or pustular psoriasis develop

Phototherapy (PUVA) as first-line systemic treatment:

• PUVA is generally considered the systemic treatment of first choice with the least toxicity 3, 4
• Start with 70% of minimum phototoxic dose, increase successive doses by 40% if no erythema 3
• Contraindicated in pregnancy, significant cataracts, age <18, and previous cutaneous malignancy 3, 4
• Requires contraception, ultraviolet A eye protection, and shielding of genitalia 3

Conventional systemic agents:

• Methotrexate: Response time 2 weeks; contraindicated in pregnancy, breastfeeding, significant hepatic damage, anaemia, leucopenia, thrombocytopenia 3
• Acitretin: Response time 6 weeks; contraindicated in pregnancy or wish to conceive within 2 years of stopping treatment 3, 4
• Cyclosporin: Response time 3 weeks; contraindicated in abnormal renal function, uncontrolled hypertension, previous/concomitant malignancy 3, 4

All systemic agents require:

• Pretreatment assessment including history, examination, and relevant laboratory tests 3
• Absolute contraception in women of childbearing age 3
• Regular monitoring with blood pressure, serum creatinine, liver function tests, and full blood count depending on agent used 3, 4

Biologic Therapy for Moderate-to-Severe Disease

Biologics represent optimal treatment for most patients with moderate-to-severe psoriasis and should become the standard of care, as they target more specific inflammatory pathways, have better safety profiles, are better tolerated, and are more effective than conventional systemic agents. 5

Adalimumab (Humira) for plaque psoriasis:

• FDA-approved for treatment of adult patients with moderate-to-severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy, and when other systemic therapies are medically less appropriate 6
• Achieves treatment goal in 68.2-79.3% of patients by week 16, with >93% achieving ≥75% reduction in psoriasis area and severity index 7
• Can be combined with methotrexate to augment efficacy or with topical high-potency corticosteroids with or without vitamin D analogues 4

Important safety considerations for biologics:

• Screen for active or latent tuberculosis, hepatitis B, and fungal infections before initiating therapy 6
• Increased risk of serious infections—do not start if active infection present 6
• Increased cancer risk, particularly lymphoma in patients with RA, and hepatosplenic T-cell lymphoma (often fatal) in young males treated concomitantly with azathioprine or 6-mercaptopurine 6
• Avoid live vaccines during treatment 6

Special Considerations for Pustular Psoriasis

For generalized pustular psoriasis, infliximab demonstrates rapid and often complete disease clearance and should be considered first-line biologic therapy, with standard dosing of 5 mg/kg infused at weeks 0,2, and 6, then every 8 weeks thereafter. 4

Critical management principles:

• Avoid systemic corticosteroids in pustular psoriasis due to risk of disease exacerbation upon discontinuation 4
• If patient is already on oral steroids during a flare, do not abruptly discontinue—initiate acitretin (0.1-1 mg/kg/day) while slowly tapering steroids 4
• Acitretin is particularly effective for pustular psoriasis with response seen as early as 3 weeks 4
• TNF antagonists should be avoided in chronic palmoplantar pustulosis as they may exacerbate this condition 4

Guttate Psoriasis Management

For acute guttate psoriasis, use lower concentrations of tar and dithranol as erupting lesions are commonly less tolerant of topical treatment, and consider ultraviolet B phototherapy which is especially helpful for this presentation. 1

• Investigate and treat streptococcal infection with phenoxymethylpenicillin or erythromycin in patients showing evidence of persistent streptococcal infection 1

Medications to Avoid

Never prescribe systemic corticosteroids for psoriasis as they can precipitate erythrodermic psoriasis, generalized pustular psoriasis, or very unstable psoriasis when discontinued. 4, 2

Other medications that worsen psoriasis: 3, 2

• Lithium, chloroquine, and mepacrine—may cause severe, potentially fatal deterioration
• Beta-blockers and non-steroidal anti-inflammatory agents in some patients
• Alcohol consumption

Drug interaction to avoid:

• Do not use salicylic acid simultaneously with calcipotriol, as acidic pH inactivates calcipotriol and reduces effectiveness 2

Common Pitfalls

Perceived "tachyphylaxis" to topical corticosteroids is often due to poor patient adherence rather than true receptor down-regulation—address compliance issues before switching therapies. 2

• Many patients with moderate-to-severe psoriasis remain undertreated due to misperceptions that psoriasis is benign and that conventional systemic therapies are safer than biologics 5
• Patients who fail to respond to one topical agent may respond to another for unclear reasons—trial alternative topical agents before escalating to systemic therapy 3, 2
• Combination treatment with two or more systemic agents carries at least additive toxicity and requires extreme caution with careful monitoring 3, 4

Comorbidity Recognition

Recognize psoriasis as a chronic multisystem inflammatory disorder to optimize management and reduce comorbidities including cardiovascular disease, obesity, metabolic syndrome, diabetes mellitus, and inflammatory bowel disease. 8

• Severity of skin symptoms is related to mortality associated with myocardial infarction, making long-term efficacious control of skin inflammation the treatment paradigm of choice 7
• Disease management is improved with maintaining ideal body weight, avoiding tobacco products, limiting alcohol, and practicing stress reduction techniques 8