What are the treatment options for plaque psoriasis?

Treatment Options for Plaque Psoriasis

For mild to moderate plaque psoriasis (<10% body surface area), initiate treatment with high-potency topical corticosteroids once or twice daily for 2-4 weeks, then transition to vitamin D analogue maintenance therapy; for moderate to severe disease (>10% BSA), biologics are first-line treatment, with topical corticosteroids added for the first 12 weeks to accelerate clearance. 1, 2

Mild to Moderate Disease (<3-10% BSA)

Initial Phase (Weeks 1-4)

• Start with class 1-3 (ultra-high to high potency) topical corticosteroids applied once or twice daily for 2-4 weeks 1, 2
• Efficacy rates range from 58-92% in randomized controlled trials 1, 2
• Select potency based on anatomical location: ultra-high potency for thick plaques on trunk/extremities, lower potency for face and intertriginous areas 2

Maintenance Phase (Weeks 5-52)

• Transition to vitamin D analogue monotherapy (calcipotriene) applied once or twice daily for up to 52 weeks to avoid corticosteroid tachyphylaxis and skin atrophy 1, 2
• Alternative: use a weekday/weekend regimen with vitamin D analogue on weekdays and high-potency corticosteroid on weekends to maintain efficacy while reducing adverse effects 1
• Never apply vitamin D analogues simultaneously with salicylic acid, as the acidic pH inactivates calcipotriene 2, 3

Combination Therapy Option

• Fixed combination calcipotriene/betamethasone dipropionate can be used once daily, providing both immediate corticosteroid effect and sustained vitamin D analogue benefit 1, 3

Moderate to Severe Disease (>10% BSA)

First-Line Treatment

• Biologics are the recommended first-line therapy for moderate to severe plaque psoriasis due to superior efficacy and acceptable safety profiles 1, 2
• TNF-α inhibitors (adalimumab, etanercept, infliximab), IL-17 inhibitors, and IL-23 inhibitors all demonstrate superior efficacy compared to traditional systemic agents 1

Specific Biologic Options

• Adalimumab: FDA-approved for moderate to severe chronic plaque psoriasis in adults who are candidates for systemic therapy or phototherapy 4
• Etanercept: achieves PASI 75 in 47% of patients at 3 months with 50 mg twice weekly dosing 1
• Infliximab: dosed at 5 mg/kg at weeks 0,2, and 6, then every 8 weeks; particularly effective when psoriatic arthritis is present 1, 2

Adjunctive Topical Therapy

• Add ultra-high potency topical corticosteroid for the first 12 weeks of biologic therapy to accelerate plaque clearance 1
• This combination approach addresses residual plaques that may persist despite biologic treatment 5

Site-Specific Treatment Approaches

Scalp Psoriasis

• Calcipotriene foam or calcipotriene plus betamethasone dipropionate gel applied for 4-12 weeks (Grade A recommendation) 1, 2
• Topical corticosteroids (classes 1-7) for at least 4 weeks are also effective 2

Facial and Intertriginous Psoriasis

• Use lower potency corticosteroids (maximum 2 weeks) to minimize atrophy risk 1, 2, 3
• Tacrolimus 0.1% ointment applied twice daily for up to 8 weeks achieves clear or almost clear status in 65-81% of patients 1, 2, 3

Nail Psoriasis

• For limited involvement (<3 nails): triamcinolone acetonide 5-10 mg/cc intralesional injections for nail matrix involvement 1
• For >3 affected nails or failed topical therapy: systemic biologics (TNF inhibitors, IL-17 inhibitors, or IL-12/23 inhibitors) are first-line treatment 1
• Infliximab is specifically recommended for moderate-to-severe nail psoriasis 1, 2

Critical Precautions and Pitfalls

Corticosteroid-Related Risks

• Monitor for skin atrophy, striae, telangiectasias, and hypothalamic-pituitary-adrenal axis suppression with prolonged use beyond 4 weeks 2, 3
• Tachyphylaxis (decreased effectiveness) occurs with continuous use, necessitating transition to maintenance therapy 2, 3

Treatment Errors to Avoid

• Never use topical therapy alone for severe whole-body psoriasis (>10% BSA), as this delays appropriate systemic treatment and leads to inadequate disease control 1
• Avoid interrupted biologic therapy, which increases antibody formation, infusion reactions, and poorer disease control 1
• Limit cyclosporine to less than 12 consecutive months due to cumulative nephrotoxicity 1

Biologic Safety Considerations

• Before starting biologics like adalimumab, screen for active infections, tuberculosis exposure, hepatitis B, and history of malignancy 4
• TNF blockers increase risk of serious infections and may increase cancer risk, particularly lymphoma in patients with RA 4
• Hepatosplenic T-cell lymphoma, though rare, has been reported in young males treated with TNF blockers plus azathioprine or 6-mercaptopurine 4

Treatment Algorithm Summary

Mild disease (<3% BSA):

• High-potency topical corticosteroid once or twice daily for 2-4 weeks → vitamin D analogue maintenance for up to 52 weeks 1

Moderate disease (3-10% BSA):

• Combination topical therapy → add narrowband UVB phototherapy or low-dose systemic therapy if inadequate response 1

Severe disease (>10% BSA):

• Initiate biologic therapy as first-line → add ultra-high potency topical corticosteroid for first 12 weeks to accelerate clearance 1, 2