What is the best treatment approach for a patient experiencing a psoriasis exacerbation?

Treatment of Psoriasis Exacerbation

For a psoriasis exacerbation, initiate high-potency topical corticosteroids (clobetasol propionate 0.05% or betamethasone dipropionate 0.05%) combined with calcipotriene (vitamin D analog), applied twice daily for a maximum of 2-4 weeks, achieving 58-92% clearance rates. 1, 2

Immediate Topical Management

First-Line Topical Therapy

• Apply clobetasol propionate 0.05% or betamethasone dipropionate 0.05% twice daily to body plaques for maximum 2-4 weeks 1, 3
• Combine with calcipotriene for synergistic effect—either as a fixed-combination product (once daily) or separate products (corticosteroid in morning, vitamin D analog in evening) 1, 2
• For scalp involvement, use clobetasol propionate 0.05% shampoo twice weekly, providing rapid symptom relief within 3-4 weeks 1

Site-Specific Modifications

• For face, genitals, and intertriginous areas: apply low-potency corticosteroids or topical calcineurin inhibitors to minimize atrophy risk 1, 2
• For body plaques with inadequate response: add tazarotene to moderate-to-high potency corticosteroids to reduce irritation while enhancing efficacy 1, 3

Critical Safety Requirements

• Implement mandatory clinical review every 4 weeks during active treatment with no unsupervised repeat prescriptions for high-potency agents 1, 3
• Limit moderate-potency corticosteroid use to maximum 100g per month 1, 3
• Require dermatological supervision for class 1-2 preparations 1, 3
• Implement periods each year when alternative treatments are employed to prevent tachyphylaxis 3

Common pitfall: The FDA warns that "in rare instances, treatment (or withdrawal of treatment) of psoriasis with corticosteroids is thought to have exacerbated the disease or provoked the pustular form" 4—therefore, never abruptly discontinue high-potency corticosteroids.

Alternative Topical Options When First-Line Fails

If the patient fails to respond to one topical agent, trial alternative agents before escalating to systemic therapy, as many patients who fail one agent will respond to another 5, 3:

• Coal tar: Start with 0.5-1.0% crude coal tar in petroleum jelly and increase concentration every few days to maximum 10% 5, 3
• Dithranol (anthralin): Start at 0.1-0.25% concentration and increase in doubling concentrations as tolerated; use "short contact mode" (15-45 minutes every 24 hours) to minimize irritancy and staining 5, 3

Escalation to Systemic Therapy

Indications for Systemic Treatment

Escalate to systemic therapy when: 1, 2, 3

• Body surface area involvement exceeds 5%
• Inadequate response to optimized topical therapy after 8 weeks
• Signs of erythrodermic or pustular psoriasis develop

First-Line Systemic Agent

• Photochemotherapy (PUVA) is the least toxic systemic agent and should be considered first-line systemic treatment 1, 2, 3
• Starting dose: 70% of minimum phototoxic dose, increasing successive doses by 40% if no erythema develops 1, 3

Conventional Systemic Agents (Second-Line)

• Methotrexate: Response time 2 weeks; especially useful in acute generalized pustular psoriasis, psoriatic erythroderma, psoriatic arthritis, and extensive chronic plaque psoriasis 1, 2, 3

  • Absolute contraindications: pregnancy, breastfeeding, wish to father children, significant hepatic damage, anemia, leucopenia, thrombocytopenia 1, 3
  • FDA warning: "Lesions of psoriasis may be aggravated by concomitant exposure to ultraviolet radiation" 6

• Cyclosporine: Response time 3 weeks; first-line for erythrodermic psoriasis with dramatic improvement during 2-3 weeks 2, 3

  • Contraindicated with abnormal renal function, uncontrolled hypertension, or malignancy 1

• Acitretin (etretinate): Response time 6 weeks; requires contraception with absolute contraindication for pregnancy or wish to conceive within 2 years of stopping treatment 1, 3

Biologic Therapy (Third-Line)

• Infliximab demonstrates rapid and often complete disease clearance for generalized pustular psoriasis and should be considered first-line biologic therapy 1, 2, 3
• Standard dosing: 5 mg/kg infused at weeks 0,2, and 6, then every 8 weeks thereafter 1, 3
• Other biologics (adalimumab, ustekinumab, etanercept) achieve treatment goals in 68.2-79.3% of patients by week 16 2

Critical Medications to Absolutely Avoid

Never prescribe systemic corticosteroids for psoriasis—they can precipitate erythrodermic psoriasis, generalized pustular psoriasis, or very unstable psoriasis when discontinued 5, 1, 2, 3

Other medications that worsen psoriasis and must be avoided: 5, 1, 2, 3

• Lithium, chloroquine, and mepacrine: Associated with severe, potentially fatal psoriasis deterioration
• Beta-blockers and NSAIDs: May worsen psoriasis in some patients
• Alcohol: Can precipitate or worsen psoriasis

Special Considerations for Specific Exacerbation Types

Guttate Psoriasis

• Often self-limiting; use low concentrations of tar and dithranol as guttate psoriasis is commonly less tolerant of topical treatment 5
• Narrow-band UVB phototherapy may be especially helpful 5
• Investigate for streptococcal infection and treat with phenoxymethylpenicillin or erythromycin if present 5

Pustular Psoriasis

• Consider infliximab as first-line biologic therapy for rapid and often complete disease clearance 1, 2, 3
• Acitretin is an alternative treatment option 1, 3
• Never use systemic corticosteroids due to risk of severe disease exacerbation upon discontinuation 1, 2, 3

Erythrodermic Psoriasis

• Initial management: apply appropriate wet dressings with mid-potency topical steroids, maintain attention to fluid balance, and rule out sepsis with blood cultures 2
• First-line systemic options: acitretin, biologic agents, cyclosporine, and methotrexate 2