What is the recommended treatment protocol for a patient with moderate to severe psoriasis?

Psoriasis Treatment Protocol

Treatment Algorithm Based on Disease Severity

For moderate to severe psoriasis, initiate biologic therapy as first-line systemic treatment, with topical calcipotriene/betamethasone dipropionate combination as adjunctive therapy for residual plaques. 1

Mild to Moderate Psoriasis (BSA <10%)

First-line topical therapy:

• Calcipotriene/betamethasone dipropionate combination products (gel, ointment, or foam) applied once daily for up to 52 weeks is the preferred initial treatment 1, 2
• This combination achieves 69-74% clear or almost clear status and provides superior efficacy compared to either agent alone 1, 2
• Alternative regimen: Apply high-potency topical corticosteroid for weeks 1-2, then switch to calcipotriene monotherapy for weeks 3-52 2

Site-specific modifications:

• Scalp psoriasis: Use calcipotriene foam or calcipotriene/betamethasone gel for 4-12 weeks 1, 2
• Facial/intertriginous psoriasis: Use tacalcitol ointment or calcipotriene combined with hydrocortisone for 8 weeks (avoid ultrapotent corticosteroids on face) 1
• Nail psoriasis: Calcipotriene/betamethasone combination reduces nail thickness, hyperkeratosis, and onycholysis 1

Phototherapy option:

• Narrowband UVB 2-3 times weekly is effective for patients who can commit to the time requirement 1
• Can be combined with methotrexate or acitretin for synergistic effect 1

Moderate to Severe Psoriasis (BSA ≥10% or significant QOL impact)

Biologic therapy is recommended as first-line systemic treatment:

TNF-α inhibitors:

• Infliximab: 5 mg/kg IV at weeks 0,2,6, then every 8 weeks (can increase frequency to every 4 weeks or dose to 10 mg/kg for better control) 1
• Adalimumab: 80 mg subcutaneous initial dose, then 40 mg every other week starting one week after initial dose 3
• Etanercept: 50 mg subcutaneous twice weekly for 12 weeks, then 50 mg once weekly maintenance (may continue 50 mg twice weekly for better control) 1

IL-17 and IL-23 inhibitors:

• Secukinumab, ustekinumab, brodalumab, tildrakizumab, guselkumab, and risankizumab are all recommended options 1
• Selection should be based on comorbidities (particularly psoriatic arthritis), patient preference for dosing frequency, and insurance coverage 1

Combination strategies to augment biologic efficacy:

• Add topical calcipotriene/betamethasone to biologic therapy for residual plaques 1, 4
• Infliximab can be combined with methotrexate or acitretin when clinically indicated 1
• Etanercept can be combined with methotrexate, acitretin, or narrowband UVB 1

Special Situations

Psoriatic arthritis (any severity):

• Biologic therapy is mandatory regardless of skin BSA involvement 1
• Infliximab and etanercept both inhibit radiographic joint damage progression 1

Erythrodermic psoriasis:

• Cyclosporine 3-5 mg/kg/day is the preferred initial treatment for systemically ill patients due to rapid onset of action 1
• Alternative options include infliximab, adalimumab, or methotrexate 1
• Acitretin has slow onset and should be avoided in acute presentations 1

Pustular psoriasis:

• Infliximab, adalimumab, or etanercept can be used 1
• Acitretin is an alternative systemic option 1

Critical Safety Considerations and Pitfalls

Topical corticosteroid use:

• Never use ultrapotent corticosteroids (clobetasol) continuously beyond 2-4 weeks without tapering 2, 5
• After clinical response, taper to once daily, then alternate days, then twice weekly 2, 6
• Maximum weekly amount of clobetasol should not exceed 50g 5
• Face and intertriginous areas have highest risk for atrophy, striae, and telangiectasia 5

Drug interactions:

• Never apply salicylic acid simultaneously with calcipotriene—the acidic pH inactivates calcipotriene 1, 2
• Apply vitamin D analogues after phototherapy sessions to avoid UVA inactivation and UVB blockage 1

Biologic therapy monitoring:

• Test for latent tuberculosis before initiating any TNF-α inhibitor and monitor for active TB during treatment 3
• Screen for hepatitis B and C before starting biologics 3
• Monitor for serious infections—discontinue biologic if sepsis or serious infection develops 3
• Increased risk of lymphoma and other malignancies, particularly hepatosplenic T-cell lymphoma in adolescents with inflammatory bowel disease 3

Pregnancy considerations:

• Narrowband UVB is first-line for moderate to severe psoriasis in pregnancy 1
• Avoid acitretin in women of childbearing potential (teratogenic for 3 years after discontinuation) 1
• Avoid methotrexate—males should wait 3 months after discontinuation before conception 1

Maintenance and Long-Term Management

Topical maintenance:

• Calcipotriene/betamethasone combination can be used safely for up to 52 weeks without significant adverse effects 1
• Weekend-only high-potency corticosteroid with weekday vitamin D analogue is effective for maintenance 1

Biologic maintenance:

• Continue biologic therapy indefinitely for sustained disease control 1
• If inadequate response after 12-16 weeks, switch to alternative biologic rather than adding second biologic 1

Treatment failure definition:

• Primary failure: Inadequate response after 12-16 weeks of appropriate dosing 1
• Secondary failure: Loss of response after initial adequate control 1
• In either case, switch to different mechanism of action rather than dose escalation alone 1