From the Guidelines
Severe psoriasis requires aggressive treatment with systemic medications or biologics, with first-line options including methotrexate, cyclosporine, or acitretin, and biologics such as TNF inhibitors, IL-17 inhibitors, IL-23 inhibitors, or IL-12/23 inhibitors, as recommended by the joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics 1.
Treatment Options
- Systemic medications: methotrexate (starting at 7.5-15mg weekly), cyclosporine (2.5-5mg/kg/day), or acitretin (25-50mg daily)
- Biologics: TNF inhibitors (adalimumab, etanercept), IL-17 inhibitors (secukinumab, ixekizumab), IL-23 inhibitors (guselkumab, risankizumab), or IL-12/23 inhibitors (ustekinumab)
Combination Therapy
- Topical therapies: potent corticosteroids (clobetasol 0.05% twice daily) or vitamin D analogs (calcipotriene once daily)
- Phototherapy: narrowband UVB three times weekly
Patient Care
- Moisturize daily
- Avoid triggers: stress, alcohol
- Regular follow-ups to monitor treatment efficacy and side effects
Disease Impact
- Severe psoriasis affects multiple body systems beyond the skin, increasing risk for cardiovascular disease, metabolic syndrome, and psychological issues, making comprehensive treatment essential for both skin clearance and overall health, as noted in the guidelines of care for the management of psoriasis and psoriatic arthritis 1.
From the FDA Drug Label
Plaque Psoriasis (Ps) (1. 7): treatment of adult patients with moderate to severe chronic plaque psoriasis who are candidates for systemic therapy or phototherapy, and when other systemic therapies are medically less appropriate. The recommended dosage for severe psoriasis is not explicitly stated, but for moderate to severe chronic plaque psoriasis, the dosage is:
- 80 mg initial dose,
- followed by 40 mg every other week starting one week after initial dose 2. Key points:
- Indication: treatment of adult patients with moderate to severe chronic plaque psoriasis
- Dosage: 80 mg initial dose, followed by 40 mg every other week
- Candidate patients: those who are candidates for systemic therapy or phototherapy, and when other systemic therapies are medically less appropriate.
From the Research
Severe Psoriasis Treatment Options
- Psoriasis is an inflammatory skin condition that affects approximately 2% of people worldwide 3
- Treatment options for psoriasis include topical treatments, systemic treatments, biologic agents, and phototherapy 3
Phototherapy for Severe Psoriasis
- Ultraviolet (UV) B phototherapy is most appropriate for patients with >10% affected body surface area who have not responded to topical treatments 3
- Narrowband UVB (NB-UVB) and targeted phototherapy are effective treatment options for psoriasis, administered two to three times weekly until clearance followed by maintenance treatment before discontinuation 3
- Long-term data on NB-UVB indicate that it has a good safety profile 3
Combination Therapy for Severe Psoriasis
- Combination of calcipotriol ointment plus NB-UVB more than twice a week is superior to other treatment regimens, rapidly improving psoriasis lesions 4
- Topical combination of corticosteroid and vitamin D derivative appears to provide a balanced approach to psoriasis treatment 5
- Calcipotriol combination led to an earlier clearance of plaques and a lesser relapse rate than the calcitriol combination 6
Safety and Efficacy of Treatment Options
- Clobetasol propionate spray 0.05% add-on therapy to a stable regimen of biologic treatment in patients with moderate to very severe plaque psoriasis is effective, but further research is needed to evaluate its safety and efficacy 7
- Both vitamin D analogues, calcipotriol and calcitriol, in combination with NBUVB phototherapy are safe, effective, and cosmetically acceptable, with calcipotriol being more efficacious 6