What are the treatment options for psoriasis?

Psoriasis Treatment

Treatment Selection Based on Disease Severity

For mild psoriasis (<5% body surface area), start with combination topical therapy using calcipotriene/betamethasone dipropionate once daily for 4-8 weeks, which achieves clear or almost clear status in 48-74% of patients. 1

Mild Psoriasis (<5% BSA)

First-line topical therapy:

• Calcipotriene/betamethasone dipropionate combination product once daily for 4-8 weeks is the optimal first-line choice 2
• For body/extremities, use class 2-5 (moderate to high potency) corticosteroids initially 2
• For thick, chronic plaques, ultrahigh-potency corticosteroids (clobetasol propionate 0.05% or halobetasol propionate 0.05%) are required 2
• Maximum continuous high-potency corticosteroid use is 4 weeks to prevent skin atrophy, striae, and telangiectasia 2

Site-specific modifications:

• For facial and intertriginous psoriasis, use low-potency corticosteroids or tacrolimus to avoid skin atrophy 1, 2
• For scalp psoriasis, use calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 1
• For nail psoriasis, apply calcipotriene combined with betamethasone dipropionate, though efficacy is limited due to poor nail matrix penetration 2

Maintenance strategy after initial control:

• Transition to weekend-only high-potency corticosteroid application (twice daily on weekends) with weekday vitamin D analogue therapy (twice daily on weekdays) to minimize corticosteroid exposure while maintaining efficacy 2
• Maximum vitamin D analogue use is 100g per week to avoid hypercalcemia 2

Critical pitfall to avoid:

• Never combine salicylic acid with calcipotriene simultaneously—the acidic pH inactivates calcipotriene and eliminates its effectiveness 2

Moderate-to-Severe Psoriasis (≥5% BSA)

Patients with symptomatic psoriasis (pain, bleeding, itching) should be considered for systemic or phototherapy even if BSA involvement is limited. 1

Treatment algorithm:

First-line: Phototherapy

• Narrowband UVB or PUVA 1
• 308-nm excimer laser for selective targeting of localized resistant areas such as scalp and skin folds 2

Second-line: Traditional systemic agents

• Methotrexate (FDA-approved since 1972, competitive inhibitor of dihydrofolate reductase) requires regular monitoring of full blood count, liver function tests, and serum creatinine 1, 2
• Cyclosporine 3-5 mg/kg/day for rapid onset of action, particularly effective for erythrodermic psoriasis requiring rapid response 2
  • Use in short 3-4 month "interventional" courses 2
  • Requires regular monitoring of blood pressure, renal function, and lipid profile 1
• Acitretin decreases keratinocyte hyperproliferation and restores normal epidermal differentiation, but cannot be used in women of childbearing potential due to teratogenicity 2

Third-line: Biologic agents

• IL-17 inhibitors, IL-23 inhibitors, IL-12/23 inhibitors, and TNF inhibitors 1
• Adalimumab (HUMIRA) for adults: 80 mg initial dose, followed by 40 mg every other week starting one week after initial dose 3
• All commonly used systemic agents are absolutely contraindicated in pregnancy 1

Combination strategies to enhance efficacy:

• Adding ultrahigh-potency (class 1) topical corticosteroid to standard dose etanercept for 12 weeks (Level I evidence) 1, 2
• Adding calcipotriene/betamethasone to standard dose adalimumab for 16 weeks accelerates clearance of psoriatic plaques 1, 2
• Adding topical calcipotriene to standard dose methotrexate therapy (Level I evidence) 1, 2
• All topical corticosteroids can be used in combination with any biologics 1, 2

Rotational therapy consideration:

• Switching between treatment modalities every 1-2 years may minimize cumulative toxicity of individual treatments 4

Psoriatic Arthritis Management

Treatment algorithm based on severity:

• For mild joint symptoms: NSAIDs 1
• For moderate-to-severe joint involvement: DMARDs (methotrexate, sulfasalazine, leflunomide) 1
• For inadequate response to at least one DMARD: TNF inhibitors 1
• For severe enthesitis that has failed therapies for mild and moderate disease: Consider TNF inhibitor 1
• TNF inhibitors like adalimumab are effective for both skin and joint symptoms 4

Special Considerations for Erythrodermic Psoriasis

For systemically ill patients with erythrodermic psoriasis, oral cyclosporine 3-5 mg/kg/day is the logical choice due to rapid and impressive onset of action. 2

• Base therapy on short-term efficacy rather than long-term considerations 2
• Transition to maintenance therapy after acute illness improves 2
• Mid-potency topical corticosteroids and emollients under occlusion may help restore barrier function, but systemic treatment is inevitably necessary 2

Critical Warnings and Contraindications

Absolute contraindications and warnings:

• Systemic corticosteroids should be avoided in psoriasis as they can cause disease flare during taper 1, 4
• Long-term use of potent topical corticosteroids can cause skin atrophy, striae, and telangiectasia 1
• Commercial sunbeds are rarely effective for psoriasis and may cause premature skin aging and increased skin fragility 1
• Vitamin D analogues should be applied after phototherapy to avoid inactivation 4

Drugs that may precipitate or worsen psoriasis:

• Alcohol, beta-blockers, NSAIDs, lithium, chloroquine, and mepacrine 4

Biologic safety warnings (adalimumab/HUMIRA):

• Increased risk of serious infections leading to hospitalization or death, including tuberculosis, bacterial sepsis, invasive fungal infections 3
• Perform test for latent TB; if positive, start treatment for TB prior to starting HUMIRA 3
• Lymphoma and other malignancies, some fatal, have been reported in children and adolescent patients treated with TNF blockers 3
• Discontinue if patient develops serious infection or sepsis during treatment 3