From the Guidelines
Plaque psoriasis treatment should typically start with topical treatments for mild to moderate cases, and biologic therapies such as TNF inhibitors (adalimumab, etanercept), IL-17 inhibitors, IL-23 inhibitors, or IL-12/23 inhibitors (ustekinumab) for severe or resistant cases, as recommended by the joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics 1.
Treatment Approach
The treatment approach for plaque psoriasis involves a stepwise approach based on disease severity. For mild to moderate cases, topical treatments are the first line, including:
- Corticosteroids (such as betamethasone or clobetasol)
- Vitamin D analogs (calcipotriene)
- Retinoids (tazarotene)
- Calcineurin inhibitors (tacrolimus) These should be applied directly to affected areas once or twice daily as prescribed.
Systemic Medications
For moderate to severe cases, phototherapy using UVB light 2-3 times weekly for 2-3 months may be effective. When these approaches are insufficient, systemic medications are considered, including:
- Methotrexate (starting at 7.5-15mg weekly) 1
- Cyclosporine (2.5-5mg/kg/day)
- Oral retinoids like acitretin (10-50mg daily)
Biologic Therapies
For severe or resistant cases, biologic therapies targeting specific inflammatory pathways are highly effective, including:
- TNF inhibitors (adalimumab, etanercept) 1
- IL-17 inhibitors (secukinumab, ixekizumab)
- IL-23 inhibitors (guselkumab, risankizumab)
- IL-12/23 inhibitors (ustekinumab) 1 These biologics are typically administered by injection every 1-12 weeks depending on the specific medication.
Lifestyle Modifications
Regardless of treatment approach, lifestyle modifications like:
- Maintaining a healthy weight
- Avoiding alcohol
- Quitting smoking
- Reducing stress can help manage symptoms. Regular moisturizing with fragrance-free products is essential to maintain skin barrier function and reduce scaling and irritation. Treatment effectiveness varies by individual, and combination approaches are often used for optimal disease control. The recommended starting dose of etanercept is 50 mg taken as a self-administered subcutaneous injection twice weekly for 12 consecutive weeks, as stated in the joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics 1.
From the FDA Drug Label
Subjects in all treatment groups and in both studies had a median baseline PASI score ranging from 15 to 17, and the percentage of subjects with baseline sPGA classifications ranged from 54% to 66% for moderate, 17% to 26% for marked and 1% to 5% for severe More subjects randomized to Enbrel than placebo achieved at least a 75% reduction from baseline PASI score (PASI 75) with a dose response relationship across doses of 25 mg once a week, 25 mg twice a week and 50 mg twice a week Among PASI 75 achievers in both studies, the median time to PASI 50 and PASI 75 was approximately 1 month and approximately 2 months, respectively, after the start of therapy with either 25 or 50 mg twice a week.
Etanercept (Enbrel) is effective for the treatment of plaque psoriasis.
- The medication has been shown to achieve a 75% reduction in PASI score in a significant proportion of patients.
- The response to treatment is dose-dependent, with higher doses resulting in greater reductions in PASI score.
- Time to response is approximately 1-2 months after starting therapy. 2
From the Research
Treatment Options for Plaque Psoriasis
- Topical agents, such as topical corticosteroids, vitamin D analogues, calcineurin inhibitors, and keratolytics, are the mainstay of treatment for mild psoriasis 3
- Biologics, including inhibitors to tumor necrosis factor α (TNF-α), are recommended as an option for first-line treatment of moderate to severe plaque psoriasis due to their efficacy and acceptable safety profiles 3
- Oral treatments, such as methotrexate, acitretin, cyclosporine, and apremilast, are also available for the treatment of plaque psoriasis 3
- Narrowband UV-B phototherapy is a commonly prescribed light therapy used to treat plaque psoriasis 3, 4
Combination Therapies
- The combination of narrowband ultraviolet B phototherapy and etanercept has been shown to be more effective than etanercept alone in the treatment of moderate-to-severe psoriasis 5
- Combination therapy with topical corticosteroids and vitamin D analogues may be beneficial for some patients 6
Treatment Optimization and Transitioning
- Dermatologists recommend continuous therapy for patients on biologicals, but dosage reduction may be considered to limit drug exposure 7
- Switching biologicals for reasons of efficacy should be done without a washout period, but switching for reasons of safety may require a treatment-free interval 7