What are the treatment options for psoriasis medical management?

Psoriasis Medical Management

Treatment Selection Based on Disease Severity

For mild psoriasis (<5% body surface area), initiate combination calcipotriene/betamethasone dipropionate once daily for 4-8 weeks, which achieves clear or almost clear status in 48-74% of patients. 1

Mild Psoriasis (Topical Therapy)

First-Line Topical Regimen:

• Start with calcipotriene/betamethasone dipropionate combination product once daily for 4-8 weeks as the most effective topical approach 1, 2
• For body/extremities: Use class 2-5 (moderate to high potency) corticosteroids initially 3
• For thick, chronic plaques: Class 1 (ultrahigh-potency) corticosteroids like clobetasol propionate 0.05% or halobetasol propionate 0.05% are required 3
• Maximum duration for continuous high-potency corticosteroid use: 4 weeks 3

Site-Specific Modifications:

• Face and intertriginous areas: Use only low-potency corticosteroids or calcitriol ointment to prevent skin atrophy 1, 4
• Scalp: Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 1, 4
• Nails: Calcipotriene combined with betamethasone dipropionate, though efficacy is limited due to poor nail matrix penetration 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
• Maximum vitamin D analogue use: 100g per week to avoid hypercalcemia 1, 5

Moderate-to-Severe Psoriasis (≥5% BSA or Symptomatic Disease)

Patients with symptomatic psoriasis (pain, bleeding, itching) should be considered for systemic or phototherapy even if BSA involvement is limited. 1, 4

Systemic Non-Biologic Options:

• Methotrexate: FDA-approved since 1972, competitive inhibitor of dihydrofolate reductase; requires regular monitoring of complete blood count, liver function tests, and serum creatinine 5, 4
• Cyclosporine 3-5 mg/kg/day: Recommended for rapid onset of action, particularly effective for erythrodermic psoriasis requiring rapid response; use in short 3-4 month "interventional" courses 1, 4
• Acitretin: Decreases keratinocyte hyperproliferation and restores normal epidermal differentiation; absolutely contraindicated in women of childbearing potential due to teratogenicity 1, 5

Biologic Therapies:

• TNF inhibitors (e.g., adalimumab): Effective for both skin and joint symptoms in psoriatic arthritis 5, 6
• IL-17 inhibitors, IL-23 inhibitors, and IL-12/23 inhibitors: Recommended as third-line treatment for moderate-to-severe psoriasis 4

Phototherapy:

• Narrowband UVB or PUVA: First-line option for moderate-to-severe psoriasis 4
• 308-nm excimer laser: Allows selective targeting of localized resistant areas such as scalp and skin folds 5

Combination Therapy Strategies

Adding Topicals to Systemic Agents:

• Adding ultrahigh-potency (class 1) topical corticosteroid to standard dose etanercept for 12 weeks is recommended for moderate to severe psoriasis (Level I evidence) 3, 4
• Adding calcipotriene/betamethasone to standard dose adalimumab for 16 weeks accelerates clearance of psoriatic plaques 3, 4
• Adding topical calcipotriene to standard dose methotrexate therapy is recommended for moderate to severe psoriasis (Level I evidence) 3, 4
• All topical corticosteroids can be used in combination with any biologics 3, 4

Topical Combination Strategies:

• Combining tazarotene with medium- or high-potency corticosteroids for 8-16 weeks increases efficacy while reducing local adverse events and prolonging remission 1
• Apply tazarotene 0.1% gel once daily plus medium/high-potency corticosteroid for synergistic effect 1

Psoriatic Arthritis Management

Treatment Algorithm:

• Mild joint symptoms: NSAIDs 4
• Moderate-to-severe joint involvement: DMARDs (methotrexate, sulfasalazine, leflunomide) 4
• Inadequate response to at least one DMARD: TNF inhibitors 4
• Severe enthesitis failing other therapies: Consider TNF inhibitor 4

Critical Pitfalls to Avoid

Medication Interactions and Contraindications:

• Never combine salicylic acid with calcipotriene simultaneously—the acidic pH inactivates calcipotriene and eliminates its effectiveness 1
• Systemic corticosteroids should be avoided in psoriasis as they can cause disease flare during taper 5, 4
• Do not use high-potency corticosteroids on face or flexures—use low-potency agents or tacrolimus instead 1
• Apply vitamin D analogues after phototherapy to avoid inactivation 5

Safety Monitoring:

• Limit continuous high-potency corticosteroid use to prevent skin atrophy, striae, telangiectasia, and HPA axis suppression 1, 4
• Long-term use beyond 12 weeks requires careful physician supervision 3
• For cyclosporine: Regular monitoring of blood pressure, renal function, and lipid profile 4
• All commonly used systemic agents are absolutely contraindicated in pregnancy 4

Biologic Safety:

• Increased risk of serious infections leading to hospitalization or death, including tuberculosis, bacterial sepsis, invasive fungal infections; discontinue if serious infection develops 6
• Perform test for latent TB; if positive, start treatment for TB prior to starting biologic therapy 6
• Monitor all patients for active TB during treatment, even if initial latent TB test is negative 6
• Lymphoma and other malignancies, some fatal, have been reported in patients treated with TNF blockers 6

Alternative Medicine Considerations

The workgroup provided expert opinion on alternative medicine therapy, which is not part of evidence-based recommendations. 3

• Traditional Chinese medicine including herbal methods should only be considered if the ingredients within the herbal blends are known and well understood 3
• Acupuncture has been used for mild to moderate psoriasis with responses relatively minor 3
• Oral curcumin supplementation may benefit as adjunctive therapy 5
• Gluten-free diet should only be considered for patients diagnosed with celiac disease 5