What are the treatment options for psoriatic plaques?

Treatment Options for Psoriatic Plaques

First-Line Treatment for Mild to Moderate Disease

For mild to moderate plaque psoriasis, start with the combination of calcipotriene 0.005% and betamethasone dipropionate 0.064% applied once or twice daily, which achieves clear or almost clear status in 69-74% of patients and can be safely used for up to 52 weeks. 1, 2

Topical Corticosteroid Monotherapy

• High-potency (Class 1-3) topical corticosteroids are recommended for 2-4 weeks as initial therapy, with efficacy rates of 58-92% in randomized controlled trials 1
• Apply 1-2 times daily, selecting potency based on disease location and severity 1
• Clobetasol propionate 0.05% spray achieves treatment success in 84.1% of patients when used twice daily for 4 weeks 3, 4
• After initial corticosteroid response, transition to vitamin D analogue for maintenance therapy (up to 52 weeks) to avoid tachyphylaxis and skin atrophy 1

Combination Therapy Strategy

• The morning-evening regimen (high-potency corticosteroid in morning, vitamin D analogue in evening) reduces adverse effects while maintaining efficacy 2
• This approach is more cost-effective and minimizes corticosteroid-related complications 2

Critical Precautions with Topical Therapy

• Never combine vitamin D analogues with salicylic acid simultaneously—the acidic pH inactivates calcipotriene 1, 5
• If using phototherapy, apply vitamin D analogues after treatment as UVA radiation decreases skin concentration 1
• Monitor for skin atrophy, striae, and HPA axis suppression with prolonged corticosteroid use 1

Treatment for Moderate to Severe Disease

Biologics are first-line treatment for moderate to severe plaque psoriasis (>10% body surface area), with TNF-α inhibitors, IL-17 inhibitors, and IL-23 inhibitors showing superior efficacy to traditional systemic agents. 1, 2

TNF-α Inhibitors

Etanercept:

• Start with 50 mg subcutaneously twice weekly for 12 weeks, then reduce to 50 mg once weekly for maintenance 6
• Achieves PASI 75 in 47% of patients at 3 months with the 50 mg twice weekly regimen 6, 7
• For inadequate response, continue 50 mg twice weekly rather than reducing to once weekly 6
• Median time to PASI 75 is approximately 2 months 7

Infliximab:

• Administer 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks 6, 1
• For inadequate response, increase frequency to every 4 weeks or increase dose up to 10 mg/kg 6
• Particularly effective for nail psoriasis and when psoriatic arthritis is present 6, 1

IL-12/23 Inhibitor

Ustekinumab:

• For patients ≤100 kg: 45 mg subcutaneously at weeks 0 and 4, then every 12 weeks 6
• For patients >100 kg: 90 mg subcutaneously at weeks 0 and 4, then every 12 weeks 6
• Escalate to 90 mg (instead of 45 mg) or increase frequency to every 8 weeks for inadequate response 6
• Achieves 35% clearance in palmoplantar psoriasis, with 67% clearance rate using 90 mg dose 6

Essential Adjunctive Topical Therapy with Biologics

Add ultrahigh potency (Class 1) topical corticosteroid for 12 weeks to biologics to accelerate clearance and target residual plaques—this combination approach prevents rapid relapse when systemics are discontinued. 2

• Combination of etanercept or adalimumab with high-potency corticosteroids is strongly recommended (Grade A) 6
• In patients on stable biologic therapy with residual plaques, adding clobetasol propionate 0.05% spray twice daily achieves clear or almost clear status in 81% with moderate disease and 79.5% with severe disease 8
• Calcipotriene/betamethasone dipropionate can be added to biologics (Grade B recommendation) 2

Site-Specific Treatment Approaches

Scalp Psoriasis

• Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks (Grade A recommendation) 1, 2
• Topical corticosteroids (Classes 1-7) for at least 4 weeks 1
• Etanercept is effective as monotherapy for scalp involvement 6

Facial and Intertriginous Psoriasis

• Use lower potency corticosteroids to minimize atrophy risk 1
• Tacrolimus 0.1% ointment for up to 8 weeks achieves clear or almost clear status in 65% of patients 6, 1
• Calcipotriene combined with hydrocortisone for 8 weeks (Grade B recommendation) 2

Nail Psoriasis

• For ≤3 affected nails: triamcinolone acetonide 5-10 mg/cc intralesional injections for nail matrix involvement 5
• For >3 affected nails or failed topical therapy: systemic biologics are first-line, particularly TNF inhibitors, IL-17 inhibitors, or IL-12/23 inhibitors 5
• Topical vitamin D analogues combined with betamethasone dipropionate reduce nail thickness and hyperkeratosis 5, 2
• Infliximab is specifically recommended for moderate-to-severe nail psoriasis 6, 1
• Ustekinumab achieves median NAPSI improvement of 42.5% at week 16,86.3% at week 28, and 100% at week 40 6

Palmoplantar Psoriasis

• Ustekinumab 90 mg achieves 67% clearance compared to 9% with 45 mg dose 6
• Infliximab is effective for plaque-type palmoplantar psoriasis 6
• Topical maxacalcitol ointment as initial treatment 2

Treatment Algorithm Based on Disease Severity

Mild disease (<3% BSA):

1. Start high-potency topical corticosteroid once or twice daily for 2-4 weeks 1
2. Add or switch to vitamin D analogue for maintenance (up to 52 weeks) 1
3. Consider combination calcipotriene/betamethasone dipropionate for optimal efficacy 1, 2

Moderate disease (3-10% BSA):

1. Combination topical therapy as above 1
2. If inadequate response, add narrowband UVB phototherapy or low-dose systemic therapy 1

Severe disease (>10% BSA):

1. Initiate biologic therapy (TNF-α, IL-17, or IL-23 inhibitor) as first-line treatment 1, 2
2. Simultaneously add ultrahigh potency topical corticosteroid for 12 weeks to accelerate clearance 2
3. Continue topical therapy during systemic treatment to prevent rapid relapse 2
4. Alternative options include methotrexate, acitretin, or cyclosporine if biologics are contraindicated 1

Common Pitfalls to Avoid

• Never use topical therapy alone for severe whole-body psoriasis—this delays appropriate systemic treatment and leads to inadequate disease control 2
• Avoid interrupted biologic therapy, as this increases antibody formation, infusion reactions, and poorer disease control 2
• Do not apply vitamin D analogues before phototherapy—apply after treatment 1
• Do not use tazarotene in pregnancy (Category X) 6
• Limit cyclosporine to less than 12 consecutive months due to cumulative nephrotoxicity 5