What are the treatment options for managing psoriasis?

Medical Management of Psoriasis

Treatment Selection Based on Disease Severity

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. 1

Mild Psoriasis: First-Line Topical Therapy

Initial regimen for body plaques:

• Apply clobetasol propionate 0.05% or betamethasone dipropionate 0.05% twice daily for maximum 2-4 weeks 1
• Combine with calcipotriene using either fixed-combination products (calcipotriene/betamethasone dipropionate gel or foam) once daily for 4-12 weeks, or separate products with corticosteroid in morning and vitamin D analog in evening 2, 1
• This combination approach enhances efficacy and reduces irritation compared to monotherapy 2

Site-specific modifications:

• Scalp: Use clobetasol propionate 0.05% shampoo twice weekly or calcipotriene foam/calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 2, 1
• Face, genitals, intertriginous areas: Apply low-potency corticosteroids (not high-potency agents) or topical calcineurin inhibitors (tacrolimus) to minimize atrophy risk 2, 1, 3
• Nails: Use calcipotriene combined with betamethasone dipropionate, though efficacy is limited due to poor nail matrix penetration 3

Maintenance strategy after achieving initial control:

• Transition to weekend-only high-potency corticosteroid application (twice daily on weekends) with weekday vitamin D analog therapy (twice daily on weekdays) to minimize corticosteroid exposure while maintaining efficacy 3
• Maximum vitamin D analog use: 100g per week to avoid hypercalcemia 3

Critical Safety Requirements for Topical Therapy

Mandatory monitoring protocols:

• Implement 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
• Maximum duration for continuous high-potency corticosteroid use is 4 weeks 3
• Long-term use beyond 12 weeks requires careful physician supervision 3

Absolute contraindications and critical pitfalls:

• Never combine salicylic acid with calcipotriene simultaneously—the acidic pH inactivates calcipotriene and eliminates its effectiveness 3
• Never prescribe systemic corticosteroids for psoriasis—they can precipitate erythrodermic psoriasis, generalized pustular psoriasis, or very unstable psoriasis when discontinued, potentially causing severe or fatal deterioration 1
• Do not use high-potency corticosteroids on face or flexures—use low-potency agents or tacrolimus instead 3

Moderate-to-Severe Psoriasis: Escalation Criteria

Escalate to systemic therapy when: 1

• Body surface area involvement exceeds 5%
• Inadequate response to optimized topical therapy after 8 weeks
• Signs of erythrodermic or pustular psoriasis develop
• Patient is symptomatic (pain, bleeding, itching) regardless of BSA 2, 3

Phototherapy for Moderate Disease

Photochemotherapy (PUVA) is the least toxic systemic agent and should be considered first-line systemic treatment for moderate-to-severe psoriasis, with starting dose at 70% of minimum phototoxic dose. 1

• Narrowband UVB and PUVA are first-line options for moderate-to-severe psoriasis 2
• The 308-nm excimer laser allows selective targeting of localized resistant areas such as scalp and skin folds 3
• Apply vitamin D analogues after phototherapy to avoid inactivation 2

Systemic Non-Biologic Therapies

For moderate-to-severe psoriasis requiring rapid response (particularly erythrodermic psoriasis), cyclosporine at 3-5 mg/kg/day provides the most rapid onset of action. 3

Cyclosporine

• Dosing: 3-5 mg/kg/day 3
• Response time: 3 weeks 1
• Duration: Use in short 3-4 month "interventional" courses 3
• Contraindications: Abnormal renal function, uncontrolled hypertension, malignancy 1

Methotrexate

• Response time: 2 weeks 1
• Mechanism: Competitive inhibitor of dihydrofolate reductase, FDA-approved since 1972 3
• Absolute contraindications: Pregnancy, breastfeeding, wish to father children, significant hepatic damage, anemia, leucopenia, thrombocytopenia 1

Acitretin

• Response time: 6 weeks 1
• Mechanism: Decreases keratinocyte hyperproliferation and restores normal epidermal differentiation 3
• Absolute contraindication: Pregnancy or wish to conceive within 2 years of stopping treatment; requires contraception 1
• Alternative for pustular psoriasis 1

Biologic Therapies for Severe Disease

For generalized pustular psoriasis, infliximab demonstrates rapid and often complete disease clearance and should be considered first-line biologic therapy. 1

Infliximab for Pustular Psoriasis

• Dosing: 5 mg/kg infused at weeks 0,2, and 6, then every 8 weeks thereafter 1

Adalimumab (HUMIRA) for Moderate-to-Severe Plaque Psoriasis

• FDA indication: 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 4
• For psoriatic arthritis: TNF inhibitors like adalimumab are effective for both skin and joint symptoms 2

Critical safety warnings for TNF blockers: 4

• Increased risk of serious infections (tuberculosis, fungal infections, bacterial/viral infections)
• Increased cancer risk, including lymphoma and hepatosplenic T-cell lymphoma (rare but often fatal, especially in young males on concomitant azathioprine/6-MP)
• Screen for tuberculosis and hepatitis B before initiating
• Do not use with other biologics (ORENCIA, KINERET, RITUXAN) or combine multiple TNF blockers 4

Other Biologic Options

• TNF inhibitors, IL-17 inhibitors, IL-23 inhibitors, and IL-12/23 inhibitors are third-line options for moderate-to-severe psoriasis 2

Combination Strategies to Enhance Systemic/Biologic Efficacy

Adding topical therapy to systemic agents accelerates clearance and improves outcomes:

• Ultrahigh-potency (class 1) topical corticosteroid added to standard dose etanercept for 12 weeks (Level I evidence) 3
• Calcipotriene/betamethasone added to standard dose adalimumab for 16 weeks accelerates clearance of psoriatic plaques 3
• Topical calcipotriene added to standard dose methotrexate (Level I evidence) 3
• All topical corticosteroids can be used in combination with any biologics 3

Special Considerations for Specific Psoriasis Types

Erythrodermic Psoriasis

• Oral cyclosporine 3-5 mg/kg/day is the logical choice for systemically ill patients due to rapid and impressive onset of action 3
• Mid-potency topical corticosteroids and emollients under occlusion may help restore barrier function but systemic treatment is inevitably necessary 3
• Base therapy on short-term efficacy rather than long-term considerations, and transition to maintenance therapy after acute illness improves 3

Psoriatic Arthritis

• NSAIDs for mild joint symptoms 2
• DMARDs for moderate-to-severe joint involvement 2
• TNF inhibitors for inadequate response to at least one DMARD 2

Medications That Worsen Psoriasis (Avoid or Use Cautiously)

Drugs that may precipitate or worsen psoriasis: 2, 1

• Systemic corticosteroids (can cause severe, potentially fatal deterioration when discontinued)
• Lithium, chloroquine, mepacrine (associated with severe, potentially fatal psoriasis deterioration)
• Beta-blockers
• NSAIDs
• Alcohol

Adjunctive and Alternative Therapies

Evidence-based adjunctive options:

• Oral curcumin supplementation may benefit patients with psoriasis of varying severity as adjunctive therapy 5
• Mindfulness meditation and stress reduction techniques (meditation, biofeedback, relaxation techniques, cognitive behavioral therapy, guided imagery) can improve psoriasis severity in some patients 5, 2
• Gluten-free diet should only be considered for patients diagnosed with celiac disease; patients with moderate to severe plaque psoriasis should be asked about GI symptoms of celiac disease 5, 2

Not recommended:

• Oral vitamin D supplementation does not directly improve disease activity at dosages that avoid hypercalcemia and calciuria 5
• Oral zinc supplementation does not improve PASI scores 5