What are the treatment options for managing psoriasis?

Psoriasis Management

Initial Treatment Approach for Mild Disease

For mild psoriasis (≤5% body surface area), initiate treatment with high-potency topical corticosteroids combined with calcipotriene (vitamin D analog), which achieves 58-92% clearance rates and provides synergistic benefit superior to either agent alone. 1, 2

Topical Corticosteroid Selection by Location

• Body plaques: Apply clobetasol propionate 0.05% (class 1, ultra-high potency) or betamethasone dipropionate 0.05% (class 2, high potency) twice daily for maximum 2-4 weeks to thick plaques 2, 3

• Scalp involvement: Use clobetasol propionate 0.05% shampoo twice weekly, leaving on scalp for 5-10 minutes before rinsing, providing rapid symptom relief within 3-4 weeks 2

• Face, genitals, intertriginous areas: Apply low-potency corticosteroids (class 5-7) or topical calcineurin inhibitors (tacrolimus 0.1%, pimecrolimus) to minimize atrophy risk 1, 2, 3

• Thick resistant plaques: Consider intralesional triamcinolone acetonide up to 20 mg/mL every 3-4 weeks for glabrous skin, scalp, nails, palms, and soles 2

Combination Topical Regimens

• Fixed-combination products: Calcipotriene/betamethasone dipropionate gel or foam provides convenient once-daily application with proven efficacy for 4-12 weeks 1, 4

• Separate product regimen: Apply high-potency corticosteroid in morning and vitamin D analog (calcipotriene) in evening for enhanced effectiveness 1

• Tazarotene addition: Combine tazarotene (topical retinoid) with moderate-to-high potency corticosteroids to reduce irritation while enhancing efficacy for body plaques 1, 2, 3

Critical Safety Monitoring Requirements

Implement mandatory clinical review every 4 weeks during active treatment with no unsupervised repeat prescriptions for high-potency agents. 2, 4

• Limit moderate-potency corticosteroid use to maximum 100g per month 1, 2, 4

• Require dermatological supervision for class 1-2 (very potent/potent) preparations 1, 2

• Plan annual periods employing alternative non-corticosteroid treatments to prevent continuous high-potency steroid exposure 2, 4

Transition to Maintenance Phase

After achieving control at 2-4 weeks, transition to weekend-only corticosteroid application while using vitamin D analogs on weekdays to minimize adverse effects including skin atrophy, striae, telangiectasia, and HPA axis suppression. 1, 2, 3

• Taper frequency gradually after clinical improvement rather than abrupt withdrawal to prevent rebound flare phenomenon 2

• Switch to the least potent agent that maintains disease control 2

Alternative Topical Options When First-Line Fails

• Coal tar: Start with 0.5-1.0% crude coal tar in petroleum jelly and increase concentration every few days to maximum 10%, recognizing cruder extracts are messier but more effective than refined products 1, 4

• Dithranol (anthralin): Begin at 0.1-0.25% concentration and increase in doubling concentrations as tolerated, using short contact mode (15-45 minutes every 24 hours) to minimize irritancy and staining 1, 4

Systemic Treatment for Moderate-to-Severe Disease

Escalate to systemic therapy when body surface area involvement exceeds 5%, inadequate response to optimized topical therapy after 8 weeks, scalp tenderness persists despite adequate anti-inflammatory treatment, or signs of erythrodermic or pustular psoriasis develop. 2, 4

First-Line Systemic Treatment Selection

Photochemotherapy (PUVA) is the least toxic systemic agent and should be considered first-line systemic treatment, with starting dose at 70% of minimum phototoxic dose (read at 72 hours) and successive doses increased by 40% of the preceding dose if no erythema develops. 1, 4

• PUVA requires pretreatment eye examination, liver function tests, and ongoing monitoring with ultraviolet A eye protection and genital shielding unless specific need to treat 1

• Response time is approximately 4 weeks 1

• Contraindications include pregnancy, clinically significant cataracts, age <18, previous cutaneous malignancy, and previous ionizing radiation 1

Conventional Systemic Agents

When phototherapy is inadequate or contraindicated, consider these options under dermatological supervision:

• Methotrexate: Response time 2 weeks; absolute contraindications include pregnancy, breastfeeding, wish to father children, significant hepatic damage, anemia, leucopenia, thrombocytopenia; requires contraception for both men and women and avoidance of interacting drugs 1, 4

• Acitretin (etretinate): Response time 6 weeks; requires contraception with absolute contraindication for pregnancy or wish to conceive within 2 years of stopping treatment; monitor liver function tests and fasting serum lipids 1, 4

• Cyclosporin: Response time 3 weeks; contraindicated with abnormal renal function, uncontrolled hypertension, or malignancy; requires blood pressure and serum creatinine monitoring 1, 4

Biologic Therapy

The American Academy of Dermatology-National Psoriasis Foundation guidelines recommend biologics as an option for first-line treatment of moderate to severe plaque psoriasis because of their efficacy and acceptable safety profiles. 5

• TNF-α inhibitors: Adalimumab, etanercept, certolizumab, infliximab achieve treatment goals in 68.2-79.3% of patients by week 16 4, 5

• IL-17 inhibitors: Secukinumab, ixekizumab, bimekizumab, brodalumab 5

• IL-23 inhibitors: Guselkumab, tildrakizumab, risankizumab, mirikizumab targeting p19 subunit 5

• IL-12/23 inhibitor: Ustekinumab targeting p40 subunit 5

Before initiating biologics, screen for active or latent tuberculosis, hepatitis B, and fungal infections, recognizing increased risk of serious infections and cancer. 6, 5

Special Consideration for Pustular Psoriasis

Infliximab demonstrates rapid and often complete disease clearance for generalized pustular psoriasis 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

• Never prescribe systemic corticosteroids for psoriasis, as they can precipitate erythrodermic psoriasis, generalized pustular psoriasis, or very unstable psoriasis when discontinued 4, 3

• Consider acitretin as an alternative treatment option for pustular psoriasis 4

Special Considerations for Guttate Psoriasis

• Use lower concentrations of tar and dithranol for acute guttate psoriasis, as erupting lesions are commonly less tolerant of topical treatment 1, 2

• Consider ultraviolet B phototherapy as especially helpful for guttate presentations 2

• Investigate and treat streptococcal infection with phenoxymethylpenicillin or erythromycin in patients with acute guttate psoriasis showing evidence of persistent streptococcal infection 2

Critical Medications to Avoid

Avoid these medications that precipitate or worsen psoriasis:

• Systemic corticosteroids: Can cause severe, potentially fatal deterioration when discontinued 4, 3

• Lithium, chloroquine, mepacrine: Associated with severe, potentially fatal psoriasis deterioration 1, 3

• Beta-blockers and NSAIDs: May worsen psoriasis in some patients 1, 3

• Alcohol: Can precipitate or worsen psoriasis 1, 3

• Salicylic acid with calcipotriene: Acidic pH inactivates calcipotriene and reduces effectiveness 1, 3

Common Pitfalls to Avoid

• Perceived "tachyphylaxis" to topical corticosteroids is often due to poor patient adherence rather than true receptor down-regulation; address compliance issues before switching therapies 4, 3

• Patients who fail to respond to one topical agent may respond to another; trial alternative topical agents before escalating to systemic therapy 1, 4

• Avoid commercially available sunbeds (ultraviolet A) as they are rarely effective and may cause premature skin aging and increased skin fragility 1

• Apply vitamin D analogues after phototherapy treatment to avoid inactivation by UVA and blocking UVB radiation 1