What is the plan of care for a patient with psoriasis?

Psoriasis Plan of Care

For patients with psoriasis, initiate treatment based on disease severity: mild disease (affecting <5% body surface area) should be managed with topical corticosteroids combined with vitamin D analogues, while moderate-to-severe disease (≥5% BSA or significant quality of life impairment) requires systemic therapy with biologics as first-line treatment, specifically IL-17 or IL-23 inhibitors, which demonstrate superior efficacy to traditional agents. 1, 2, 3

Initial Assessment

Severity Determination

• Assess body surface area (BSA) involvement to stratify disease severity: <5% BSA indicates mild disease, 5-10% BSA indicates moderate disease, and >10% BSA indicates severe disease 1, 4
• Evaluate patient-reported disability and quality of life impact, as subjective burden may not correlate with objective disease extent 1
• Screen for psoriatic arthritis by asking about joint pain, stiffness, and swelling, as 30% of psoriasis patients develop inflammatory arthritis requiring rheumatology referral 1, 5

Comorbidity Screening

• Check blood pressure according to national guidelines, referring patients with BP ≥140/90 mmHg to primary care for hypertension management 1
• Order fasting lipid panel and glucose/HbA1c to screen for metabolic syndrome, as psoriasis patients have significantly elevated cardiovascular risk 1, 4, 3
• Screen for depression and suicide ideation using validated tools, as psychiatric comorbidity is substantially increased in psoriasis 1, 6

Medication Review

• Immediately discontinue or avoid lithium, chloroquine, mepacrine, beta-blockers, and NSAIDs, as these medications can precipitate severe, life-threatening psoriasis flares 1, 7
• Never prescribe systemic corticosteroids for psoriasis, as withdrawal precipitates erythrodermic or generalized pustular psoriasis 1, 7, 8

Treatment Algorithm by Severity

Mild Psoriasis (<5% BSA)

First-Line Topical Therapy

• Apply betamethasone dipropionate 0.05% combined with calcipotriene (vitamin D analogue) once daily for 4-8 weeks, as this combination represents the most effective first-line topical therapy 1, 2, 7
• Limit moderately potent corticosteroids (BNF grade III) to ≤100g per month with mandatory clinical review every 4 weeks and no unsupervised refills 1
• Implement corticosteroid-free periods annually by rotating to alternative agents to prevent tachyphylaxis and skin atrophy 1

Second-Line Options for Topical Failure

• Escalate to clobetasol propionate 0.05% (ultra-high potency) twice daily for maximum 2-4 weeks if medium-potency corticosteroids fail, achieving 68-92% clearance rates 2
• Add coal tar preparations starting at 0.5-1.0% crude coal tar in petroleum jelly, increasing concentration every few days to maximum 10% as an extremely safe, cost-effective alternative 1, 2
• Consider dithranol (anthralin) 0.1-0.25% in short-contact mode (15-45 minutes daily), doubling concentration as tolerated, though expect skin staining and irritation 1, 2

Moderate-to-Severe Psoriasis (≥5% BSA or Significant QOL Impairment)

First-Line Systemic Therapy

• Prescribe IL-17 inhibitors (secukinumab, ixekizumab, brodalumab) or IL-23 inhibitors (guselkumab, risankizumab, tildrakizumab) as first-line biologics for moderate-to-severe plaque psoriasis, per American Academy of Dermatology-National Psoriasis Foundation guidelines 3, 9
• Consider TNF-α inhibitors (adalimumab, etanercept, infliximab, certolizumab) as alternative first-line biologics, particularly if concurrent psoriatic arthritis is present 10, 3
• Adalimumab 40mg subcutaneously every other week achieves 59% PASI-75 response at 24 weeks and is FDA-approved for both psoriasis and psoriatic arthritis 10

Alternative Systemic Options

• Initiate methotrexate as the most cost-effective systemic option for self-pay patients, though requires weekly monitoring of liver function tests and carries teratogenicity risk 1, 2, 3
• Consider phototherapy (narrowband UVB or PUVA) as the least toxic systemic intervention, starting PUVA at 70% of minimum phototoxic dose and increasing by 40% if no erythema develops 7, 3, 9
• Prescribe apremilast (phosphodiesterase-4 inhibitor) as an oral option for patients declining biologics or phototherapy 3, 9

Special Populations

Psoriatic Arthritis

• Refer immediately to rheumatology for any patient with joint symptoms, as early treatment prevents irreversible structural damage 1, 5
• Prioritize TNF-α inhibitors, IL-17 inhibitors, or IL-12/23 inhibitors as these biologics treat both skin and joint manifestations 10, 3

Guttate Psoriasis

• Manage most cases in primary care with topical therapy, as guttate psoriasis often self-resolves within weeks to months 1

Pregnant or Breastfeeding Patients

• Avoid methotrexate entirely due to teratogenicity, requiring contraception during treatment and for ≥1 menstrual cycle after discontinuation 1
• Avoid retinoids (acitretin) with mandatory contraception for 2 years after treatment completion due to prolonged teratogenic risk 1

Monitoring Requirements

During Active Treatment

• Conduct clinical review every 4 weeks to assess treatment response using BSA or PASI scoring and monitor for adverse effects 1, 2, 7
• Perform laboratory monitoring based on chosen therapy: weekly liver function tests for methotrexate, biweekly creatinine/blood pressure for cyclosporine 1
• Never provide unsupervised repeat prescriptions for high-potency topical corticosteroids 1, 2

Long-Term Management

• Reassess cardiovascular risk factors annually including blood pressure, lipids, glucose, and body weight 1
• Screen for depression at each visit using standardized tools, as biologic therapy improves both skin disease and psychiatric symptoms concurrently 1
• Monitor for treatment failure defined as <50% improvement in PASI or BSA after 12-16 weeks of systemic therapy 1

Adjunctive Therapies

Lifestyle Modifications

• Recommend weight loss for obese patients, as bariatric surgery should be considered for BMI >40 kg/m² when standard weight loss measures fail 1
• Advise smoking cessation and alcohol limitation, as both worsen psoriasis severity 1
• Encourage stress reduction techniques including mindfulness meditation and cognitive behavioral therapy, which improve disease severity 1

Complementary Approaches

• Consider oral curcumin supplementation as adjunctive therapy, though evidence is limited 1
• Implement gluten-free diet only for patients with confirmed celiac disease after positive antibody testing and gastroenterology consultation 1
• Do not recommend vitamin D or zinc supplementation for psoriasis treatment, as oral supplementation does not improve disease activity 1

Critical Pitfalls to Avoid

• Never combine salicylic acid with calcipotriene, as salicylic acid inactivates the vitamin D analogue 2
• Never use ultra-high potency corticosteroids beyond 4 weeks continuously due to skin atrophy, striae, and systemic absorption risk 2
• Never attribute treatment failure to "tachyphylaxis" without first addressing adherence, as perceived corticosteroid resistance is usually poor compliance 7
• Never delay systemic therapy referral for patients with ≥5% BSA involvement or significant quality of life impairment despite adequate topical therapy 2, 7