What is the treatment for psoriasis?

Treatment of Psoriasis

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

Disease Severity Classification

Psoriasis severity determines treatment approach:

• Mild psoriasis is defined as <5% body surface area (BSA), generally asymptomatic, with minimal quality of life impact 2, 3
• Moderate-to-severe psoriasis is defined as ≥5% BSA OR involvement of vulnerable areas (face, genitals, hands/feet, nails, scalp, intertriginous areas) OR symptomatic disease (pain, bleeding, itching) OR significant quality of life impact 2, 3
• Even limited BSA involvement warrants systemic therapy if the patient is symptomatic or has significant quality of life impairment 3

Treatment Algorithm for Mild Psoriasis

First-Line Topical Therapy

Use calcipotriene/betamethasone dipropionate combination product once daily for 4-8 weeks as initial therapy, which provides superior efficacy compared to either agent alone 1:

• Apply to affected areas once daily for 4-8 weeks 1
• This combination achieves 48-74% of patients reaching clear or almost clear status 1
• Maximum vitamin D analogue use: 100g per week to avoid hypercalcemia 1

Site-Specific Modifications

• For scalp psoriasis: Use calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 3
• For facial/intertriginous psoriasis: Use low-potency corticosteroids or tacrolimus to avoid skin atrophy 3, 1
• For thick, chronic plaques on body/extremities: Use class 1 ultrahigh-potency corticosteroids (clobetasol propionate 0.05% or halobetasol propionate 0.05%) for maximum 4 weeks continuous use 1
• For nail psoriasis: Apply 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 with weekday vitamin D analogue therapy to minimize corticosteroid exposure while maintaining efficacy 1:

• Apply high-potency topical corticosteroid twice daily on weekends only 1
• Apply vitamin D analogue twice daily on weekdays 1
• This approach prevents tachyphylaxis and reduces risk of skin atrophy 1

Critical Pitfalls to Avoid

• Never combine salicylic acid with calcipotriene simultaneously—the acidic pH inactivates calcipotriene completely 1
• Never use systemic corticosteroids as monotherapy in psoriasis—they cause severe disease flare during or after taper 2
• Limit continuous high-potency corticosteroid use to 4 weeks maximum to prevent skin atrophy, striae, telangiectasia, and HPA axis suppression 1
• Do not use high-potency corticosteroids on face or flexures—use low-potency agents or tacrolimus instead 1

Treatment Algorithm for Moderate-to-Severe Psoriasis

First-Line Systemic Therapy Options

When topical therapy fails or disease is moderate-to-severe, proceed to systemic therapy:

Phototherapy (narrowband UVB or PUVA) is recommended as first-line treatment for moderate-to-severe psoriasis 3:

• Narrowband UVB phototherapy is the most commonly prescribed light therapy 4
• PUVA (psoralen plus UVA) is an alternative for extensive disease 3

Second-Line: Traditional Systemic Agents

If phototherapy is inadequate or inappropriate, use traditional systemic agents 3:

• Methotrexate: FDA-approved since 1972, competitive inhibitor of dihydrofolate reductase; requires monitoring of complete blood count, liver function tests, and serum creatinine 3, 1
• Cyclosporine 3-5 mg/kg/day: Provides rapid onset of action, particularly effective for erythrodermic psoriasis; use in short 3-4 month "interventional" courses; requires monitoring of blood pressure, renal function, and lipid profile 3, 1
• Acitretin: Decreases keratinocyte hyperproliferation; cannot be used in women of childbearing potential due to teratogenicity; slower onset than cyclosporine 3, 1

Third-Line: Biologic Therapy

For inadequate response to traditional systemic agents, initiate biologic therapy with IL-17 inhibitors, IL-23 inhibitors, or IL-12/23 inhibitors 3:

Preferred First-Line Biologics

• Ustekinumab (IL-12/23 inhibitor) is recommended as a first-line biologic agent 5
• Adalimumab (TNF inhibitor) is recommended as first-line, particularly when psoriatic arthropathy is present 5, 6
• Secukinumab (IL-17 inhibitor) can be considered as first-line biologic with or without psoriatic arthritis 5

Biologic Dose Escalation Strategies

If initial biologic dosing provides inadequate response, escalate dose before switching agents 5:

Biologic Agent	Dose Escalation Strategy
Ustekinumab 45 mg every 12 weeks (<100 kg)	Increase to 90 mg every 12 weeks [5]
Ustekinumab 90 mg every 12 weeks (>100 kg)	Increase to 90 mg every 8 weeks [5]
Adalimumab 40 mg every other week	Increase to 40 mg weekly [5]
Etanercept 50 mg once weekly	Increase to 50 mg twice weekly [5]
Infliximab 5 mg/kg every 8 weeks	Increase to 5 mg/kg every 6 weeks [5]

When to Switch Biologics

Switch to an alternative biologic when the current treatment fails to achieve minimum response criteria or loses effectiveness over time 5:

• Evaluate for modifiable factors contributing to poor response first 5
• Consider dose escalation before switching 5
• If inadequate response persists, switch to alternative biologic agent 5

Combination Strategies to Enhance Efficacy

Adding topical therapies to biologic treatment significantly enhances efficacy 5, 3:

• Adding ultrahigh-potency (class 1) topical corticosteroid to standard dose etanercept for 12 weeks improves outcomes in moderate-to-severe psoriasis (Level I evidence) 3, 1
• Adding calcipotriene/betamethasone to standard dose adalimumab for 16 weeks accelerates clearance of psoriatic plaques 5, 3, 1
• Adding topical calcipotriene to standard dose methotrexate improves outcomes (Level I evidence) 3, 1
• All topical corticosteroids can be combined with any biologic 3, 1

Special Considerations for Psoriatic Arthritis

When joint involvement is present, treatment must address both skin and joint manifestations:

• For mild joint symptoms: Use NSAIDs 2, 3
• For moderate-to-severe joint involvement: Use DMARDs (methotrexate, sulfasalazine, leflunomide) 2, 3
• For inadequate response to at least one DMARD: Initiate TNF inhibitors 2, 3
• For severe enthesitis failing other therapies: Consider TNF inhibitor 3

Adalimumab is particularly recommended when psoriatic arthropathy is a consideration because it treats both skin and joint disease effectively 5, 6.

Adjunctive and Alternative Approaches

• Stress reduction techniques (meditation, cognitive behavioral therapy) can improve psoriasis severity in some patients 2, 5
• Oral curcumin supplementation may benefit patients as adjunctive therapy 5
• Maintaining ideal body weight, avoiding tobacco, limiting alcohol, and stress reduction improve disease management 7

Treatment Goals and Monitoring

Treatment success is defined as ≥75% reduction in PASI (Psoriasis Area and Severity Index) from baseline 8:

• Continue treatment if PASI reduction is ≥75% 8
• Modify treatment regimen if PASI improvement is <50% 8
• **If PASI improvement is ≥50% but <75%**: Modify therapy if DLQI (Dermatology Life Quality Index) is >5, but can continue if DLQI is ≤5 8

Safety Monitoring Requirements

• For methotrexate: Monitor complete blood count, liver function tests, and serum creatinine regularly 3
• For cyclosporine: Monitor blood pressure, renal function, and lipid profile regularly 3
• For high-potency corticosteroids beyond 12 weeks: Requires careful physician supervision 1
• For all systemic agents: Absolutely contraindicated in pregnancy 3