What are the treatment options for a patient with psoriasis?

Treatment Options for Psoriasis

For mild psoriasis (≤5% body surface area), initiate treatment with high-potency topical corticosteroids combined with calcipotriene (vitamin D analog), which achieves 58-92% clearance rates and represents the most effective first-line approach. 1, 2, 3

Topical Therapy for Mild Disease

First-Line Topical Regimens

• Apply clobetasol propionate 0.05% or betamethasone dipropionate 0.05% twice daily for maximum 2-4 weeks to body plaques, combined with calcipotriene for synergistic effect 1, 2, 3

• Fixed-combination calcipotriene/betamethasone dipropionate gel or foam provides convenient once-daily application with proven efficacy for 4-12 weeks 3, 4

• Alternative separate product regimen: apply high-potency corticosteroid in morning and vitamin D analog in evening for enhanced effectiveness 3

Site-Specific Considerations

• For face, genitals, and intertriginous areas: use low-potency corticosteroids or topical calcineurin inhibitors (tacrolimus, pimecrolimus) to minimize atrophy risk 1, 2, 3, 5

• For scalp involvement: use clobetasol propionate 0.05% shampoo twice weekly, providing rapid symptom relief within 3-4 weeks 3

• For thick body plaques: add tazarotene to moderate-to-high potency corticosteroids to reduce irritation while enhancing efficacy 1, 3

Critical Safety Monitoring for Topical Corticosteroids

• Implement mandatory clinical review every 4 weeks during active treatment with no unsupervised repeat prescriptions for high-potency agents 6, 3

• Limit moderate-potency corticosteroid use to maximum 100g per month 6, 1, 3

• Require dermatological supervision for class 1-2 (very potent/potent) preparations 6, 3

• Implement periods each year when alternative treatments are employed to prevent tachyphylaxis 1, 3

Alternative Topical Options When First-Line Fails

• Coal tar: start with 0.5-1.0% crude coal tar in petroleum jelly and increase concentration every few days to maximum 10%; cruder extracts are messier but more effective than refined products 6, 1

• Dithranol (anthralin): start at 0.1-0.25% concentration and increase in doubling concentrations as tolerated; use "short contact mode" leaving on skin for only 15-45 minutes every 24 hours to minimize irritancy and staining 6, 1

Common Pitfall: Perceived "tachyphylaxis" to topical corticosteroids is often due to poor patient adherence rather than true receptor down-regulation—address compliance issues before switching therapies 1. Patients who fail to respond to one topical agent may respond to another, so trial alternative topical agents before escalating to systemic therapy 6, 1.

Systemic Therapy for Moderate-to-Severe Disease

Indications for Systemic Treatment

Escalate to systemic therapy when:

• Body surface area involvement exceeds 5% 1, 2, 3
• Inadequate response to optimized topical therapy after 8 weeks 1, 3
• Severe psoriatic arthropathy is present 1
• Signs of erythrodermic or pustular psoriasis develop 2, 3

First-Line Systemic Options

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

• Narrowband UVB phototherapy is first-line for pregnant women with moderate to severe psoriasis, as it lacks systemic toxicities and immunosuppressive properties 2

Conventional Systemic Agents

• 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, 2, 3

• Acitretin: response time 6 weeks; consider as alternative for pustular psoriasis 1, 2, 3

  • Absolute contraindication: pregnancy or wish to conceive within 2 years of stopping treatment 3

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

  • Contraindications: abnormal renal function, uncontrolled hypertension, or malignancy 3

Biologic Therapy

• Biologics (adalimumab, infliximab, ustekinumab, etanercept) achieve treatment goals in 68.2-79.3% of patients by week 16, and can be combined with methotrexate or topical high-potency corticosteroids 1, 2

• Infliximab demonstrates rapid and often complete disease clearance for generalized pustular psoriasis and should be considered first-line biologic therapy, with standard dosing of 5 mg/kg infused at weeks 0,2, and 6, then every 8 weeks thereafter 1, 2, 3

Critical Safety Considerations for Biologics

• Screen for active or latent tuberculosis, hepatitis B, and fungal infections before initiating therapy 1, 7

• Increased risk of serious infections and malignancy, including lymphoma and hepatosplenic T-cell lymphoma in adolescent and young adults with inflammatory bowel disease 7

• Discontinue if patient develops serious infection or sepsis during treatment 7

Special Considerations for Guttate Psoriasis

• Guttate psoriasis is commonly a self-limiting condition; many patients have no further attacks after one episode 6

• Use low concentrations of tar and dithranol as erupting guttate psoriasis is less tolerant of topical treatment 6

• Ultraviolet B radiation may be especially helpful for guttate psoriasis 6

• Investigate for streptococcal infection and treat with phenoxymethylpenicillin or erythromycin if evidence of persistent infection 6

• Repeated attacks after documented tonsillitis is an indication for referral to otolaryngology for consideration of tonsillectomy 6

Critical Medications to Absolutely Avoid

• NEVER prescribe systemic corticosteroids for psoriasis—they precipitate erythrodermic psoriasis, generalized pustular psoriasis, or very unstable disease upon discontinuation 1, 2, 3

• Avoid lithium, chloroquine, and mepacrine—associated with severe, potentially fatal psoriasis deterioration 2, 3

• Beta-blockers and NSAIDs may worsen psoriasis in some patients 3

• Avoid salicylic acid with calcipotriene—acidic pH inactivates calcipotriene and reduces effectiveness 3

Adjunctive and Alternative Therapies

• Stress reduction techniques (mindfulness meditation, biofeedback, cognitive behavioral therapy) can improve psoriasis severity and should be discussed with interested patients as adjunctive therapy 6

• Topical Aloe vera may have efficacy in mild psoriasis for patients who are not allergic, though risk of contact dermatitis exists 6

• Acupuncture may have therapeutic effect on chronic plaque psoriasis and can be considered as adjunctive therapy based on patient interest 6