40. Psoriasis

Assess disease severity: e.g., based on estimated body surface area (BSA) affected.

Provide supportive care.

Topical pharmacotherapy (e.g., corticosteroids, calcipotriene, retinoids) and/or targeted phototherapy

Systemic agents if treatment response is insufficient

Systemic pharmacotherapy

And/or phototherapy

• Narrowband UVB therapy

• PUVA therapy

Consider adjunctive topical pharmacotherapy.

Topical corticosteroids (first-line)

• Face, neck, or skin folds (i.e., areas with sensitive/thin skin): low-potency (e.g., hydrocortisone 1%)

• Scalp, trunk, and extremities

  • Medium-potency (e.g., triamcinolone 0.1%)

  • High-potency (e.g., fluocinonide 0.05%)

Topical calcineurin inhibitors: e.g., tacrolimus 0.03 % or 0.1%, or pimecrolimus 1%

• Alternative to steroids for areas with sensitive/thin skin

• May be used for maintenance after > 4 weeks of steroid use

Additional therapy: the following agents may be used in combination with topical corticosteroids

• Vitamin D analogues: e.g., calcipotriene/calcipotriol

• Keratolytics: retinoids (e.g., tazarotene), or salicylic acid

• Tar preparations, e.g., 1% coal tar lotion

• Anthralin

Principles of systemic therapy

• Management should be specialist guided

• Before therapy initiation, obtain baseline laboratory studies (e.g., BMP, CBC, liver chemistries).

Common indications

• Moderate to severe psoriasis

• Mild psoriasis with insufficient response to topical agents

Treatment options

• Biologics

  • IL-17 inhibitors, e.g., brodalumab, secukinumab

  • IL-23 inhibitors, e.g., ustekinumab , guselkumab

  • TNF-α inhibitors, e.g., etanercept, adalimumab, infliximab

• Other medications

  • Methotrexate PLUS folic acid to reduce the adverse effects

  • Cyclosporine

  • Apremilast

Provide topical treatment with ointments (e.g., petroleum jelly) and moisturizers to prevent moisture loss.

Counsel on reducing alcohol consumption and smoking cessation.

Provide management for any comorbid mental health conditions (e.g., MDD, anxiety).