Psoriasis Treatment Guidelines

Disease Classification and Treatment Selection

The American Academy of Dermatology recommends that psoriasis severity be categorized as mild (typically <5% body surface area [BSA]) or moderate-to-severe (≥5% BSA or involvement of vulnerable areas) 1, 2
Patients with symptomatic psoriasis (pain, bleeding, itching) should be considered for systemic or phototherapy even if BSA involvement is limited 2
Quality of life impact should be considered when selecting therapy, as psychological distress can be significant regardless of physical extent 1, 2

For mild psoriasis (<5% BSA), first-line treatment includes topical therapies such as topical corticosteroids, vitamin D analogues, and combination products 1, 2
For moderate-to-severe psoriasis (≥5% BSA), first-line treatment includes phototherapy with narrowband UVB or PUVA 1, 3
Traditional systemic agents such as methotrexate, cyclosporine, and acitretin are recommended as second-line treatment for moderate-to-severe psoriasis 1, 4, 5
Biologic agents such as IL-17 inhibitors, IL-23 inhibitors, and IL-12/23 inhibitors are recommended as third-line treatment for moderate-to-severe psoriasis 1

For scalp psoriasis, calcipotriene foam or calcipotriene plus betamethasone dipropionate gel is recommended for 4-12 weeks 2
For facial and intertriginous psoriasis, low-potency corticosteroids are recommended to avoid skin atrophy 2
For palmoplantar pustular psoriasis, moderately potent topical corticosteroids, coal tar, dithranol, or systemic etretinate are recommended 3

For mild joint symptoms, NSAIDs are recommended 1
For moderate-to-severe joint involvement, DMARDs such as methotrexate, sulfasalazine, and leflunomide are recommended 6
For inadequate response to at least one DMARD, TNF inhibitors are recommended 6

Combination therapy with topical corticosteroids plus vitamin D analogues enhances efficacy and reduces irritation 2
Maintenance therapy with intermittent topical steroid application or vitamin D analogues can help prolong remission 2

Systemic corticosteroids should be avoided in psoriasis as they can cause disease flare during taper 1
Long-term use of potent topical corticosteroids can cause skin atrophy, striae, and telangiectasia 1
Commercial sunbeds are rarely effective for psoriasis and may cause premature skin aging and increased skin fragility 5
All commonly used systemic agents are absolutely contraindicated in pregnancy 5

For methotrexate, regular monitoring of full blood count, liver function tests, and serum creatinine is recommended 5
For cyclosporine, regular monitoring of blood pressure, renal function, and lipid profile is recommended 5

The American Academy of Dermatology recommends combination therapy with topical corticosteroids plus vitamin D analogs for mild to moderate psoriasis, achieving enhanced efficacy and reduced irritation compared to monotherapy, with Level I evidence 7
Coal tar preparations are recommended for mild to moderate psoriasis with Level I-II evidence 7

Adding ultra-high potency (Class I) topical corticosteroid to standard dose etanercept for 12 weeks is recommended for moderate to severe psoriasis (Level I evidence) 7
Adding calcipotriene/betamethasone to standard dose adalimumab for 16 weeks is recommended to accelerate clearance of psoriatic plaques 7
Adding topical calcipotriene to standard dose methotrexate therapy is recommended for moderate to severe psoriasis (Level I evidence) 7
All topical corticosteroids can be used in combination with any biologics for moderate to severe psoriasis 7

NSAIDs are recommended for mild joint symptoms 8
DMARDs (methotrexate, sulfasalazine, leflunomide) are recommended for moderate-to-severe joint involvement 8
TNF inhibitors are recommended for inadequate response to at least one DMARD 8
For severe enthesitis that has failed therapies for mild and moderate disease, a TNF inhibitor should be considered 8