Management of Chronic Plaque Psoriasis
Treatment Selection Based on Disease Severity
For mild psoriasis (<5% body surface area), start with combination topical therapy using calcipotriene plus betamethasone dipropionate applied once daily for 4 weeks, which provides superior efficacy to monotherapy and reduces adverse effects of either agent alone. 1, 2
For moderate-to-severe psoriasis (≥5% BSA), biologic therapy with adalimumab or other TNF inhibitors is recommended as first-line systemic treatment, with adalimumab dosed at 80 mg initial dose, followed by 40 mg subcutaneous injection 1 week later, then 40 mg every 2 weeks thereafter. 1, 3
Topical Therapy Algorithm for Mild Disease
First-Line Topical Regimens
Combination vitamin D analogue (calcipotriene) plus potent corticosteroid (betamethasone dipropionate) as a single product applied once daily is the most effective topical approach, achieving maximal improvement within 4 weeks in the majority of patients. 1, 4, 5
The two-compound product permits once-daily application, improving adherence compared to separate applications. 1, 4
This combination works through complementary mechanisms: vitamin D analogues inhibit epidermal hyperproliferation and induce keratinocyte differentiation, while corticosteroids suppress pro-inflammatory cytokines. 6
Alternative Topical Regimens
Apply vitamin D analogues twice daily on weekdays combined with high-potency topical corticosteroids twice daily on weekends for maintenance therapy. 1
Morning high-potency topical corticosteroids with evening topical vitamin D analogues is an effective alternative regimen. 1
Tazarotene 0.1% cream or gel applied once daily for 8-12 weeks is recommended for mild to moderate psoriasis, though it is less effective than potent corticosteroids. 1, 5
Critical Pitfalls to Avoid
Never combine salicylic acid with calcipotriene simultaneously—the acidic pH completely inactivates calcipotriene and eliminates its effectiveness. 1, 7
Apply vitamin D analogues after phototherapy sessions, not before, to avoid inactivation by UVA and blocking of UVB radiation. 1, 2
Limit continuous high-potency corticosteroid use to 4 weeks maximum for initial treatment to prevent skin atrophy, striae, and telangiectasia. 1, 7
Avoid systemic corticosteroids entirely in psoriasis as they cause severe disease flare during taper. 2
Systemic and Biologic Therapy for Moderate-to-Severe Disease
First-Line Biologic Options
Adalimumab is recommended as monotherapy for moderate-to-severe plaque psoriasis, with 71% of patients achieving PASI 75 at week 16 compared to 7% with placebo. 1, 3
Standard adalimumab dosing: 80 mg at week 0 (given as two 40-mg injections), then 40 mg at week 1, followed by 40 mg every 2 weeks. 1, 3
For inadequate responders, increase maintenance dose to 40 mg weekly for better disease control. 1
Infliximab is an alternative first-line biologic dosed at 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks, with 80% achieving PASI 75. 1
Etanercept is dosed at 50 mg subcutaneously twice weekly for 12 weeks, then 50 mg once weekly, achieving PASI 75 in 48% at week 12. 1
Combination Strategies to Augment Biologic Efficacy
Combine adalimumab with high-potency topical corticosteroids with or without vitamin D analogues to augment efficacy. 1
Add methotrexate to adalimumab or infliximab to possibly augment efficacy and reduce immunogenicity, particularly important with infliximab. 1
Combine biologics with narrowband UVB phototherapy to enhance efficacy, though long-term safety data are limited. 1
Critical Safety Considerations
Screen all patients for latent tuberculosis before initiating any biologic therapy; if positive, start TB treatment prior to starting the biologic. 3
Monitor all patients for active TB during treatment, even if initial latent TB test is negative. 3
Discontinue biologic therapy immediately if serious infection or sepsis develops. 3
Be aware that lymphoma and other malignancies, some fatal, have been reported in patients treated with TNF blockers including adalimumab. 3
Ensure patients are up-to-date on vaccinations before starting biologic therapy. 8
Site-Specific Treatment Approaches
Scalp Psoriasis
For scalp psoriasis, apply calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks as first-line treatment. 1, 7
Generic clobetasol propionate 0.05% solution applied twice daily is highly effective, widely available, and among the least expensive prescription treatments. 7
If inadequate response after 4 weeks of high-potency corticosteroids, add calcipotriene solution on weekdays with corticosteroid use on weekends only. 7
Facial and Intertriginous Psoriasis
Use tacalcitol ointment or calcipotriene combined with hydrocortisone for 8 weeks for facial psoriasis. 1
Low-potency corticosteroids are recommended for facial and intertriginous areas to avoid skin atrophy. 2
Nail Psoriasis
Topical vitamin D analogues combined with betamethasone dipropionate can reduce nail thickness, hyperkeratosis, onycholysis, and pain, though efficacy is limited for severe nail disease due to poor penetration. 1
Adalimumab is recommended as monotherapy for moderate-to-severe plaque psoriasis affecting the nails. 1
Palmoplantar Psoriasis
Adalimumab is recommended as monotherapy for moderate-to-severe palmoplantar psoriasis. 1
Infliximab can be recommended as monotherapy for plaque-type palmoplantar psoriasis. 1
Special Populations and Conditions
Psoriatic Arthritis
For patients with psoriatic arthritis of any severity, adalimumab is recommended as monotherapy, as it treats both skin and joint symptoms and inhibits radiographic joint damage. 1, 2
- Infliximab is also recommended for psoriatic arthritis and inhibits radiographically detected joint damage. 1
Pustular or Erythrodermic Psoriasis
Adalimumab can be recommended as monotherapy for pustular or erythrodermic subtypes of moderate-to-severe psoriasis. 1
Infliximab may be recommended as monotherapy for pustular or erythrodermic subtypes. 1
Pediatric Patients
Etanercept is FDA-approved for pediatric patients aged 4 years and older with severe plaque psoriasis. 8
For juvenile idiopathic arthritis or pediatric uveitis in patients 2 years and older: 10 mg every other week for weight 10-15 kg, 20 mg every other week for 15-30 kg, and 40 mg every other week for ≥30 kg. 3
Monitoring and Maintenance
Long-Term Management
Long-term use of topical vitamin D analogues (up to 52 weeks) is recommended for mild to moderate psoriasis. 1
Combination products with calcipotriol and corticosteroids can be used for up to 52 weeks. 1
For infliximab, avoid abnormally long intervals between infusions (>8 weeks) as this increases risk of infusion reactions and loss of efficacy due to antibody formation. 1