Psoriasis Treatment Guidelines
Introduction to Psoriasis Management
- The American Academy of Dermatology recommends initiating treatment with high-potency topical corticosteroids combined with calcipotriene for mild psoriasis, achieving 58-92% clearance rates 1
Topical Therapy
- For mild psoriasis, apply clobetasol propionate 0.05% or betamethasone dipropionate 0.05% twice daily for a maximum of 2-4 weeks to thick plaques 1, 2
- Combine with calcipotriene for synergistic effect and enhanced efficacy 1, 3
- Fixed-combination products simplify regimens and improve compliance 3
Phototherapy
- Narrowband UVB is a primary option for moderate-to-severe psoriasis 1, 3
- PUVA is the least toxic systemic agent and first-line systemic treatment, with starting dose at 70% of minimum phototoxic dose read at 72 hours 4, 1
Systemic Non-Biologic Therapies
- Methotrexate is especially useful in acute generalized pustular psoriasis, psoriatic erythroderma, psoriatic arthritis, and extensive chronic plaque psoriasis in elderly or infirm patients 4, 6
- Cyclosporin at 3-5 mg/kg/day provides the most rapid onset of action for moderate-to-severe psoriasis requiring rapid response 1
- Retinoids are very effective in acral or generalized pustular forms of psoriasis 4, 6
Biologic Therapies
- Infliximab demonstrates rapid and often complete disease clearance as first-line biologic therapy for generalized pustular psoriasis 1
- Adalimumab is effective for both skin and joint symptoms in psoriatic arthritis 1
Special Considerations
- Palmoplantar psoriasis may warrant systemic therapy even if BSA <5% due to quality-of-life impact 10, 9
- Psoriatic arthritis requires systemic therapy even if skin involvement <5% BSA 10, 9
- Narrowband UVB phototherapy is first-line for moderate-to-severe psoriasis in pregnant women, avoiding systemic agents 2
- Methotrexate is absolutely contraindicated during pregnancy and breastfeeding 2