What is the psoriasis treatment protocol according to Indian guidelines?

Psoriasis Treatment Protocol: Indian Context

Disease Severity Classification

Body Surface Area (BSA) measurement is the primary tool for severity assessment and treatment stratification in Indian clinical practice 1.

• Mild psoriasis: <5% BSA, generally asymptomatic with minimal quality of life impact 2, 3
• Moderate-to-severe psoriasis: ≥5% BSA OR involvement of vulnerable areas (face, hands, feet, genitals) OR symptomatic disease OR DLQI >10 2, 3
• Special considerations: Severe scalp or palmoplantar psoriasis affecting <5% BSA may warrant systemic therapy due to significant quality of life impact 1

First-Line Treatment: Mild Psoriasis (<5% BSA)

Apply calcipotriene/betamethasone dipropionate combination product once daily for 4-8 weeks, achieving clear or almost clear status in 48-74% of patients 2, 3.

Alternative regimens:

• Clobetasol propionate 0.05% or betamethasone dipropionate 0.05% twice daily for maximum 2-4 weeks for body plaques 2
• For scalp psoriasis: calcipotriene foam or calcipotriene plus betamethasone dipropionate gel for 4-12 weeks 3

Critical pitfall: Avoid systemic corticosteroids, lithium, chloroquine, and mepacrine due to severe deterioration risk including erythrodermic transformation 2.

Second-Line Treatment: Moderate-to-Severe Psoriasis (≥5% BSA)

Phototherapy (First-Line for Moderate-to-Severe Disease)

Narrowband UVB phototherapy 2-3 times weekly is the preferred initial systemic approach due to efficacy, cost-effectiveness, and lack of systemic immunosuppression 1, 2, 3.

• PUVA (psoralen plus UVA): Start at 70% of minimum phototoxic dose, given 2-3 times weekly 1
• Treatment duration: Typically 30-40 treatments for noticeable response 1
• Contraindications: Lupus erythematosus, porphyria, xeroderma pigmentosum, pregnancy 1
• Monitoring: Regular full skin examination due to photocarcinogenesis risk in Caucasians after 200 treatments; risk not present for non-Caucasians 1

Third-Line Treatment: Traditional Systemic Agents

Methotrexate (Most Cost-Effective First-Line Systemic Agent)

Methotrexate is the most widely prescribed traditional systemic therapy worldwide and the most cost-effective option with longest safety data 1, 4.

• Dosing: Start 7.5-15 mg weekly, increase gradually based on response 1
• Response time: 2 weeks 3
• Baseline monitoring: Complete blood count, liver function tests, hepatitis profile, serum creatinine 1, 3
• Ongoing monitoring: CBC, LFTs, serum creatinine every 4-8 weeks 1, 3
• Contraindications: Pregnancy (Category X), active liver disease, significant alcohol consumption, renal impairment 1
• Critical pitfall: Avoid trimethoprim-sulfamethoxazole and other folate antagonists due to severe bone marrow suppression 1

Cyclosporine (For Rapid Response)

Cyclosporine 3-5 mg/kg/day provides the most rapid response among traditional systemic agents 2, 3, 4.

• Duration: Limited to 3-4 months for acute flares or maximum 1 year in US guidelines 1
• Baseline monitoring: Blood pressure, serum creatinine, lipid profile 3
• Ongoing monitoring: Blood pressure every 2 weeks initially, then monthly; serum creatinine and lipids monthly 3
• Contraindications: Uncontrolled hypertension, renal impairment, active infections 1
• Critical concern: Significant glomerulosclerosis risk with long-term use (3-5 years) 1

Acitretin

Acitretin is particularly effective when combined with phototherapy, producing synergistic effects and reducing cumulative UV exposure 1.

• Dosing: 25-50 mg daily 1
• Monitoring: Lipid profile, liver function tests 1
• Contraindications: Pregnancy (teratogenic for 3 years after discontinuation in women; men should avoid conception for 3 months after discontinuation) 1

Fourth-Line Treatment: Biologic Therapies

IL-17 inhibitors, IL-23 inhibitors, or IL-12/23 inhibitors are recommended for severe disease or inadequate response to traditional systemic agents 2, 3.

TNF-α Inhibitors

Adalimumab:

• Dosing: 80 mg week 0,40 mg week 1, then 40 mg every other week subcutaneously 1
• Efficacy: 80% achieve PASI-75 at 12 weeks; 68% at 60 weeks 1
• Advantage: Effective for both skin and joint symptoms in psoriatic arthritis 2
• Baseline monitoring: PPD, LFTs, CBC, hepatitis profile 1

Etanercept:

• Dosing: 50 mg twice weekly for 12 weeks, then 50 mg once weekly 1
• Efficacy: 49% achieve PASI-75 at 12 weeks with 50 mg twice weekly 1

Infliximab:

• Dosing: 5 mg/kg IV at weeks 0,2,6, then every 6-8 weeks 1
• Efficacy: 80% achieve PASI-75 at week 10; 50% improvement by week 2 1

IL-12/23 Inhibitor

Ustekinumab:

• Dosing: 45 mg at weeks 0,4, then every 12 weeks for patients <100 kg; 90 mg same schedule for ≥100 kg 1, 5
• Efficacy: 67% achieve PASI-75 at 12 weeks; 87% maintain response at 52 weeks 1

Combination Strategies for Enhanced Efficacy

Adding topical corticosteroids to biologic therapy significantly enhances efficacy 5.

• Class 1 topical corticosteroids added to standard-dose etanercept for 12 weeks improves outcomes 3, 5
• Calcipotriene/betamethasone added to adalimumab accelerates plaque clearance 5
• Methotrexate combined with narrowband UVB or PUVA produces synergistic effects, reducing treatment duration and cumulative UV doses 1

Psoriatic Arthritis Management

Escalate treatment based on joint symptom severity 2, 3:

1. Mild joint symptoms: NSAIDs 3
2. Moderate-to-severe joint involvement: DMARDs (methotrexate, sulfasalazine, leflunomide) 3
3. Inadequate response to ≥1 DMARD: TNF inhibitors (adalimumab, etanercept, infliximab, golimumab) 2, 3

Comorbidity Screening (Critical for Indian Population)

All patients with psoriasis require cardiovascular risk assessment 1:

• Blood pressure screening: Every 3-5 years if normal (<120/80 mmHg) and age 18-39; yearly if age ≥40 or BP 130-139/85-89 mmHg 1
• Diabetes screening: Every 3 years for adults aged 40-70 with BMI ≥25 kg/m² 1
• Lipid screening: Every 4-6 years for adults aged 20-79 with standard risk factors 1
• Risk score adjustment: Apply 1.5 multiplication factor for patients with BSA >10% or candidates for systemic/phototherapy 1

Dose Escalation Strategies for Biologic Failure

When current biologic therapy loses effectiveness, consider dose escalation before switching 5:

Current Regimen	Dose Escalation Strategy
Ustekinumab 45 mg every 12 weeks (<100 kg)	Ustekinumab 90 mg every 12 weeks [5]
Ustekinumab 90 mg every 12 weeks (>100 kg)	Ustekinumab 90 mg every 8 weeks [5]
Adalimumab 40 mg every other week	Adalimumab 40 mg weekly [5]
Etanercept 50 mg once weekly	Etanercept 50 mg twice weekly [5]
Infliximab 5 mg/kg every 8 weeks	Infliximab 5 mg/kg every 6 weeks [5]

Adjunctive Therapies

Stress reduction techniques improve psoriasis severity in some patients 1, 5:

• Mindfulness meditation (guided) improves outcomes in moderate psoriasis qualifying for phototherapy 1
• Cognitive behavioral therapy and guided imagery can improve severity 1
• Oral curcumin supplementation may benefit patients as adjunctive therapy 1, 5

Gluten-free diet: Only for patients diagnosed with celiac disease; trial period of 3 months if celiac antibodies positive 1

Indian-Specific Considerations

Key challenges in Indian clinical practice 4, 6:

• Average 7.8-month delay from symptom onset to dermatologist consultation 6
• 44% of patients initially visit general physicians; approximately 25% use home remedies before seeking medical help 6
• Only one-third of dermatologists use PASI for disease severity assessment 6
• Only 35% of patients comply with current treatment 6
• Treatment satisfaction highest for mild disease (62%), with only 52% overall patient satisfaction 6