What are the treatment options for plaque psoriasis?

From the Guidelines

Plaque psoriasis treatment should start with topical treatments, including corticosteroids, vitamin D analogs, and retinoids, and progress to phototherapy or systemic medications, such as methotrexate, cyclosporine, or biologics like adalimumab or etanercept, based on disease severity and patient response. The treatment approach for plaque psoriasis is guided by the severity of the disease and the patient's response to initial treatments. For mild to moderate cases, topical treatments are the first line, including:

• Corticosteroids (such as betamethasone or clobetasol)
• Vitamin D analogs (calcipotriene)
• Retinoids (tazarotene) These should be applied directly to affected areas once or twice daily as prescribed. For moderate to severe cases, phototherapy using UVB light 2-3 times weekly for 2-3 months may be effective 1. When these options fail, systemic medications become necessary, including:
• Methotrexate (starting at 7.5-15mg weekly)
• Cyclosporine (2.5-5mg/kg/day)
• Oral retinoids like acitretin (10-50mg daily) Newer biologic therapies target specific immune pathways and include:
• TNF inhibitors (adalimumab, etanercept) 1
• IL-17 inhibitors (secukinumab, ixekizumab)
• IL-23 inhibitors (guselkumab, risankizumab)
• IL-12/23 inhibitors (ustekinumab) These biologics are typically administered by injection every 1-12 weeks depending on the specific medication. According to the joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics, etanercept is recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis 1. Additionally, adalimumab is recommended as a monotherapy treatment option for adult patients with moderate-to-severe plaque psoriasis 1. Psoriasis is driven by immune dysregulation causing rapid skin cell turnover, and these treatments work by reducing inflammation, normalizing skin cell production, or modulating immune responses. Regardless of treatment choice, patients should moisturize regularly, avoid triggers like stress and alcohol, and maintain follow-up appointments to monitor treatment efficacy and potential side effects. The most recent guidelines also support the use of systemic nonbiologic therapies, such as methotrexate and cyclosporine, for the treatment of psoriasis 1. In summary, the treatment of plaque psoriasis should be individualized based on disease severity, patient response, and potential side effects, with a focus on reducing morbidity, mortality, and improving quality of life.

From the FDA Drug Label

Plaque Psoriasis (Ps) (1. 7): 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. To treat moderate to severe chronic (lasting a long time) plaque psoriasis (Ps) in adults who have the condition in many areas of their body and who may benefit from taking injections or pills (systemic therapy) or phototherapy (treatment using ultraviolet light alone or with pills).

Plaque Psoriasis Treatment: Adalimumab (HUMIRA) is indicated for the treatment of adult patients with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy.

• Key Points:
  • Treatment of adult patients with moderate to severe chronic plaque psoriasis
  • Candidates for systemic therapy or phototherapy
  • When other systemic therapies are medically less appropriate 2 2

From the Research

Plaque Psoriasis Treatment Options

• Topical agents, including topical corticosteroids, vitamin D analogues, calcineurin inhibitors, and keratolytics, are the mainstay of treatment for mild psoriasis 3
• Biologics, such as inhibitors to tumor necrosis factor α (TNF-α), are recommended as an option for first-line treatment of moderate to severe plaque psoriasis due to their efficacy and acceptable safety profiles 3
• Oral treatments, including traditional agents like methotrexate, acitretin, and cyclosporine, as well as advanced small molecules like apremilast, are also used to treat plaque psoriasis 3
• Light therapy, such as narrowband UV-B phototherapy, is another treatment option for plaque psoriasis 3

Topical Corticosteroids in Plaque Psoriasis

• Topical corticosteroids have been used for over 50 years to treat mild-to-moderate plaque psoriasis 4
• A systematic review of 50 randomized controlled trials found that topical corticosteroids were effective in treating plaque psoriasis, with 30-90% of patients experiencing more than 50% improvement in psoriasis severity 4
• Maintenance intermittent treatment with topical corticosteroids appears to be useful in prolonging remission 4

Comparative Studies of Topical Treatments

• A comparative study of topical calcipotriol and topical methotrexate found that both treatments were effective in reducing lesions in patients with chronic mild to moderate plaque psoriasis 5
• Another study found that the combination of potent and superpotent corticosteroids with vitamin D analogues provides an improvement of psoriasis within 2 weeks, reaching a maximal improvement after 4 weeks in the majority of patients 6
• A systematic review and network meta-analyses of topical therapies for plaque psoriasis found that strategies containing potent corticosteroids (alone or in combination with a vitamin D analogue) or very potent corticosteroids dominated the treatment hierarchy 7

Safety and Efficacy of Topical Treatments

• Topical calcipotriol and methotrexate were found to be well tolerated with mild and transient adverse effects, and did not alter hematological and biochemical parameters 5
• The combination of corticosteroids with vitamin D analogues has been studied extensively and is considered an efficacious and safe treatment option 6
• Corticosteroids are highly effective in psoriasis when used continuously for up to 8 weeks and intermittently for up to 52 weeks, with limited data available on long-term efficacy and safety 7