Psoriasis Management

Evaluation

Severity of Disease 

The severity of psoriasis is defined by subjective and objective qualitative assessment based on BSA involvement, location, severity, number of lesions, response to topical treatments, associated physical disability, presence or absence of psoriatic arthritis, psychosocial effects, and impact on the quality of life of the patient.  

The assessment of severity may also be done using Psoriasis Area and Severity Index (PASI), Physician’s Global Assessment (PGA), Patient’s Global Assessment, or Dermatology Life Quality Index (DLQI). 

PASI is more specific in quantifying the extent and severity of psoriasis by taking into account not only the BSA but also the intensity of plaque thickness, redness, and scaling with scores ranging from 0 (no disease) to 72 (maximal disease severity) but is rarely used in clinical practice. PASI is the best validated tool which showed good internal consistency, good intraobserver variation, and acceptable interobserver variation. PGA measures psoriasis severity and response to treatment based on erythema, induration, and scaling. DLQI is an important tool for the assessment of psoriasis severity and the treatment response in clinical trials and is seldom used in clinical practice. DLQI includes 10 questions addressing symptoms, mental health, impact on daily life, leisure, work and school, personal relationships, and the burden of psoriasis treatment.

Based on the guideline released by the American Academy of Dermatology last 2020, the severity of the disease may also be defined by the total BSA involved: 

• BSA of <3%: Mild 
• BSA of ≥3% but <10%: Moderate
• BSA of ≥10%: Severe 

The assessment of the quality of life is based on the patient’s coping strategies, daily activities, the presence of distress, and the impact of disease on relationships.

Comorbidities that affect the severity of psoriasis include psoriatic arthritis, IBD, psychological or psychiatric disorders, uveitis, cardiovascular diseases, hepatic disease (eg impaired liver function, alcoholic liver disease), malignancy (eg lymphoma), sleep apnea, chronic obstructive pulmonary disease, renal disease, lifestyle choices (eg smoking, alcoholism), and metabolic syndrome. 

Principles of Therapy

The goals of treatment include controlling the signs and symptoms, ensuring long-term effective therapy to prevent complications, and enhancing and sustaining the patient’s health-related quality of life. Treatment of psoriasis is composed of induction and maintenance phases. The induction phase is the initial stage of therapy aimed at quickly reducing the severity of psoriasis symptoms within the first 12-16 weeks. The maintenance phase follows the induction phase once the symptoms have been controlled, aiming to sustain the achieved level of improvement and prevent the relapse of severe symptoms. The choice of therapy in managing psoriasis should be individualized based on age, the severity of the disease, the presence of comorbidities, the cost of treatment, the risks and benefits of treatment, patient preference, and healthcare services access, and is also based on the shared decision between patients and healthcare providers. A treat-to-target strategy is recommended wherein treatment is modified if treatment goal is not achieved. The clinician should be familiar with all the treatment options so that the right therapy can be chosen for each individual patient as most patients will undergo multiple simultaneous therapies.  

Mild or mild-moderate disease can usually be treated by topical therapy alone while moderate-severe or severe disease usually requires phototherapy or systemic therapy including biologic agents. A treatment regimen can be modified to increase efficacy by increasing the dose, decreasing dose intervals, adding a topical agent, adding another systemic agent, or changing the drug. Combination therapy may be considered when the patient fails to respond to monotherapy. Biologic therapy is used as monotherapy and may be combined with topical agents (eg corticosteroids, vitamin D analogues) or other systemic agents to increase effectiveness or decrease potential adverse effects.

The choice and frequency of therapy will be influenced by the severity of the disease, BSA involved, body region involved, effect of psoriasis on the quality of life, and degree of psychological impairment caused by the disease. Individual factors such as the patient's age and weight, presence of comorbidities (eg hepatic disease, IBD, hypertension, heart failure), plans for conception, treatment preference, and the likelihood of treatment adherence may also affect the choice and frequency of therapy. The goals of therapy, disease phenotype, activity pattern, presence of psoriatic arthritis, and outcomes of prior psoriatic treatments should also be considered. The risk versus benefit ratio must be considered for each treatment regimen along with the availability and cost of therapy. 

Vaccinations

One may consider administration of influenza, hepatitis A and B, tetanus-diphtheria, and pneumococcal vaccines prior to therapy. Once immunosuppressive therapy is initiated, live vaccines and live-attenuated vaccines should be avoided. Avoid live vaccinations in infants until 6 months of age if mothers have received biologic therapy beyond 16 weeks gestation.

Pharmacological therapy

Topical Therapy

Topical therapy is considered the first-line treatment for mild plaque psoriasis. It may be used as an adjunctive treatment for resistant localized lesions in patients receiving phototherapy or systemic agents.  

Emollients¹

Emollients are considered the standard adjunctive therapeutic approach to the treatment of psoriasis. They are used in combination with other topical treatments. One study established that the combination increases the efficacy of corticosteroids and provides better control of psoriasis with lower doses of corticosteroids. They soften and smoothen the stratum corneum, achieved by a trapping mechanism that decreases the rate of transepidermal water loss. Emollients restore the epidermal barrier function aiding in moisturizing dry skin, reducing scaliness and itchiness, and enhancing the penetration of other topical agents. Proper skin hydration prevents irritation and potential development of new lesions at trauma sites.
 
Patient preference and the treatment area will determine the formula used (eg Petrolatum, Liquid paraffin, Mineral oils, Glycerine). Petrolatum has a more occlusive but less humectant effect than mineral oil. 

¹Various emollient products for psoriasis are available. Please see the latest MIMS for specific formulations and prescribing information.

Calcineurin Inhibitors

Example drugs: Pimecrolimus, Tacrolimus

Calcineurin inhibitors are indicated for psoriasis located in the facial and intertriginous areas only. They are not generally effective in plaque psoriasis. They work by blocking the synthesis of inflammatory cytokines that have an important role in the pathogenesis of psoriasis. 

Corticosteroids  

Corticosteroids are the first-line treatment for patients with mild or limited psoriasis and for plaque psoriasis. It is the primary agent for scalp psoriasis. They have anti-inflammatory, antiproliferative, immunosuppressive, and vasoconstrictive effects.  

Tachyphylaxis (development of tolerance) leading to decreased efficacy and side effects from long-term treatment may limit their use; hence, it should be used judiciously to obtain maximum benefits with the minimum side effects.  

They are available in different potencies from mild to very high. Low-to-mid potency may be used on the face, intertriginous areas, and sites that are susceptible to atopy. It should not be used at any site for >8 weeks. Combination with vitamin D is recommended as the initial treatment for adults with trunk and/or limb psoriasis. Mid-potency steroids are recommended as the initial treatment for the scalp, face, flexures, and genital psoriasis.  

For high to very high-potency corticosteroids, the highest-potency agents were found to be the most effective followed by vitamin D analogues. They are used as short-term therapy for rapid control. Potent to very potent topical corticosteroids are not advisable for use on the face, flexures, and genitals, over 4 weeks, and in children <1 year old. Very high-potency corticosteroids may be used on areas with thick chronic plaques.  

The choice of product will depend on the site of the lesion to be treated, the age of the patient, patient preference, the severity or thickness of lesions, and steroid potency and formulation. For the scalp, lotions, sprays, solutions, foams and gels are preferred since they can be rubbed on the scalp. Low potency is recommended for the face, and potent steroids should be avoided. For the body folds, cream or gel of low potency is recommended. For the palms and soles, very potent steroids are typically necessary, however, they are only mildly effective. Ointment is preferred. Topical corticosteroids are used concomitantly with moisturizers. 

Use corticosteroids as an adjunct with agents that are better tolerated and increase the potency of corticosteroids during flare-ups and taper down when in remission. They are commonly used in combination with vitamin D analogues, tar, topical retinoid, ultraviolet (UV) light, or systemic agents. A flare-up of psoriasis may occur upon discontinuation; hence, corticosteroid therapy should be reduced slowly. Advise regular skin examination for all patients having long-term treatment to assess atrophy. 



Dithranol (Anthralin)  

Dithranol is recommended for the treatment of mild-moderate psoriasis for short contact and is an effective treatment for large plaque psoriasis. It is commonly used as short-contact therapy (20 to 30 minutes) in an outpatient setting. It works by slowing down the proliferation of stem cells and preventing T-lymphocyte activation so that normal keratinization may occur.  

It has lower efficacy than more potent topical corticosteroids or vitamin D analogues.  It is not suitable for large areas of small lesions, flexure areas, or the face, and it may be used on the trunk and limbs only when treatment with other topicals has failed. Staining and irritating properties may limit its use.

Keratolytics  

Salicylic acid is the most commonly used keratolytic that is recommended for mild-moderate psoriasis.  

Keratolytics remove hyperkeratosis, break down, peel off excess scales, and soften the psoriatic plaques. They may be used alone or in combination with other forms of therapy (eg corticosteroids and topical immunomodulators). The combination is more effective because of increased skin penetration. Salicylic acid in combination with topical steroids may be considered for the treatment of moderate-severe psoriasis involving ≤20% of BSA, including palmar-plantar psoriasis. It should not be used together with other oral salicylates or before UVB phototherapy. 

Retinoid  

Tazarotene is a topical retinoid that is effective in psoriasis. It may be used for the treatment of mild-moderate psoriasis involving ≤10% of BSA, including palmar-plantar psoriasis and nail psoriasis. It works by mediating cell differentiation and proliferation.  

It has similar efficacy to topical corticosteroids, and it can achieve remission of psoriatic plaques. It may be combined with topical corticosteroids to enhance therapeutic effects, reduce the local irritation produced by retinoids, and reduce the treatment duration.  

Retinoids have a slow onset of action and when used as monotherapy, skin irritation (retinoid dermatitis) may limit use. They are considered teratogenic and therefore, should not be used in pregnant women or those planning to become pregnant.

Roflumilast  

Roflumilast is a phosphodiesterase-4 (PDE4) inhibitor indicated for topical treatment of plaque psoriasis, including intertriginous areas, in patients ≥12 years old. PDE4 inhibition affects the migration and actions of pro-inflammatory cells including neutrophils and other leukocytes, T-lymphocytes, monocytes, macrophages, and fibroblasts.

Tapinarof  

Tapinarof is an aryl hydrocarbon receptor-modulating agent indicated for the topical treatment of plaque psoriasis in adults. It improves psoriasis via modulation of T helper type 17 (Th17) cytokines (eg IL-17A and IL-17F), normalization of the skin barrier, and antioxidant activity.

Tars²   

Tars are effective for use in chronic plaques in mild-moderate psoriasis. They reduce keratinocyte proliferation by suppressing DNA synthesis, suppressing inflammation, and may affect immunological function.  

Tars may be used if vitamin D analogues and corticosteroids are ineffective or not tolerated. They may also be used alone as a tar bath or applied directly to psoriatic plaques and should be avoided on the face and flexures.

They are most popularly used as scalp treatment with corticosteroids or combined with UVB (Goeckerman treatment). They may cause sterile folliculitis and have low patient tolerance as most products are messy and odorous.  

²Many tar preparations in combination with other psoriasis medications are available. Please see the latest MIMS for specific formulations and prescribing information.

Vitamin D Analogues 

Examples: Calcipotriene (Calcipotriol), Calcitriol, Maxacalcitol, Tacalcitol 

Vitamin D analogues are indicated in chronic plaque psoriasis, especially for long therapy and for patients with mild-moderate scalp psoriasis. The combination of Calcipotriene and Betamethasone is recommended for 4-12 weeks for patients with mild-moderate scalp psoriasis and may be considered for up to 52 weeks to prevent relapse. Tacalcitol or Calcipotriene combined with steroids may be considered in patients with facial psoriasis. Calcipotriene or Calcitriol may be used alone or with topical corticosteroids for intertriginous psoriasis. Calcitriol appears to be less irritating on sensitive (eg skin folds) or intertriginous areas of the skin compared with Calcipotriene. They inhibit keratinocyte proliferation and enhance keratinocyte differentiation after binding to vitamin D receptors. Studies showed more improvement in psoriasis when used in combination with topical corticosteroids than when either agent is used alone. 

Other Topical Treatments (Alternative Medicine)

Examples: Aloe vera, St John's wort, vegetable oils (VGO), virgin coconut oil (VCO)  

The above examples may be considered in patients with mild psoriasis without contraindications. St John's wort should be used with caution in patients undergoing phototherapy. Vegetable oils have a more pro-inflammatory effect than virgin coconut oil. When compared to vegetable oils, virgin coconut oil has a more occlusive and humectant effect, diffuses more, has faster penetration on dry, thick, scaly skin for cell repair, and has more anti-inflammatory effect.

Systemic Non-biologic Therapy

Systemic non-biologic therapy is a recommended treatment for patients with moderate-severe psoriasis. It is administered in intermittent or rotational regimens to prevent cumulative toxicity. It is suitable for patients with good response and without fast relapses. Treatment may be discontinued abruptly or tapered off when the treatment goal has been achieved for a period of ≥6 months, when severe adverse effects occur, upon the patient's request or when clinically indicated. Treatment interruption may lead to recurrence or relapse and re-introduction of therapy may be considered if PSA ≥5 and/or DLQI ≥5.

Indications for systemic non-biological therapy include the following:

• Symptoms cannot be controlled by topical medications or
• Total well-being (psychological, physical, social) greatly affected or 
• ≥1 of the following:
  • Diagnosed moderate-severe or severe psoriasis or
  • Localized, affected part significantly impaired or distressed or
  • Failure of phototherapy (treatment failure or relapse >50% of baseline within 3 months) 

Apremilast  

Apremilast is a small phophodiesterase-4 inhibitor that can inhibit inflammatory response by regulating pro-inflammatory cytokines.  

It is indicated in adult patients with moderate-severe plaque psoriasis, especially for scalp and palmar-plantar psoriasis, who are candidates for phototherapy or systemic therapy. It may be used during induction therapy and for long-term therapy. It may also be considered if an oral treatment is preferred, and the patient has inadequate response, intolerance, or contraindications to conventional systemic agents.  

Studies demonstrated a 75% reduction in PASI score at week 16 as compared to the placebo.

Ciclosporin (Cyclosporine)

Ciclosporin inhibits T-cell activation and is a potent immunosuppressant that binds cyclophilin which inhibits calcineurin and blocks proinflammatory signaling.  

It is reserved for intermittent control and should not be given for >12 weeks unless clinically indicated. It is effective for moderate-severe plaque-type psoriasis, severe recalcitrant psoriasis, and erythrodermic, generalized pustular, and/or palmoplantar psoriasis.  

It is considered a first line in treatment of patients with indications for systemic non-biologic therapy and who need fast control of their disease, who have palmoplantar pustulosis, need systemic therapy but have plans to have children in the future, and had treatment failure after Methotrexate therapy or have disease flare-up while on preexisting systemic therapy.  

Combination with topical Calcipotriene and Betamethasone is recommended for the treatment of moderate-severe psoriasis. Ciclosporin has been used with topical vitamin D analogue or Methotrexate which lowers the effective dose of both agents. It should only be used by experienced practitioners and in patients who have failed topical treatment, phototherapy, and other systemic treatments.  

If possible, rotate its use with other treatments or use it during severe inflammatory flare-ups. It should only be used for <1 year since long-term use (>2 years) can lead to nephrotoxicity and possible malignancies (eg squamous cell carcinoma and non-melanoma skin cancers). Cyclosporine must not be used concurrently with phototherapy (eg narrowband ultraviolet B [NB UVB] and Psoralen plus ultraviolet A [PUVA]) and in patients with previous history of PUVA exposure.  

Corticosteroids  

Systemic corticosteroids are generally not recommended as they can lead to generalized pustular psoriasis and rebound exacerbations. It should only be used if absolutely needed. Intralesional steroids may be considered for unresponsive lesions and areas with very thick lesions on glabrous skin, scalp, nails, palms, and soles. 

Deucravacitinib  

Deucravacitinib is an oral tyrosine kinase 2 inhibitor indicated for the treatment of adults with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. It is not recommended for use in combination with other potent immunosuppressants. 

Dimethyl fumarate  

Dimethyl fumarate possesses immunomodulatory, antiangiogenesis, and antioxidant effects. It is a recommended option in adults with moderate-severe plaque psoriasis who are intolerant, unresponsive, or with contraindications to other systemic agents (eg Ciclosporin, Methotrexate) and PUVA.  

Studies reported a significant reduction in PASI score and improvement in quality of life as compared to the placebo. Side effects like gastrointestinal disturbance and flushing may limit use. 

Hydroxyurea  

Hydroxyurea inhibits DNA replication and is an antimetabolite that can be effective as monotherapy, though less effective than other systemic agents. It is a treatment option for patients who fail topical therapies, UVB, or who cannot tolerate PUVA, Methotrexate, or other systemic therapies.
 
Nearly half of the patients who show improvement with Hydroxyurea develop bone marrow toxicity with leukopenia or thrombocytopenia. It should be avoided in pregnant and breastfeeding women.

Methotrexate  

Methotrexate is an inhibitor of folate biosynthesis and thereby impairing DNA replication and has cytostatic and anti-inflammatory properties. It is an antimetabolite that may be used in patients who have failed topical therapies and photochemotherapy.  

It is the most frequently used agent in moderate-severe, recalcitrant, and disabling psoriasis (psoriasis covering >10% BSA). It is the first-line conventional systemic therapy for moderate-severe psoriasis. It is highly effective, especially for the long-term treatment of severe forms of psoriasis including psoriatic erythroderma and pustular psoriasis. It is recommended to give subcutaneous dosing to patients on oral treatment with a suboptimal response and consider it as the initial route of administration in patients with high need.  

Combination with topical Calcipotriene is recommended for the treatment of moderate-severe psoriasis. Combination with NB UVB may be considered for patients with generalized plaque psoriasis.  

Methotrexate may be taken with Folate supplements to reduce its toxicity. Side effects like bone marrow depression, hepatotoxicity, or pneumonitis may limit its use; therefore, monitoring of liver function tests, CBC, and renal profile is recommended. It should be avoided in pregnant and breastfeeding women. 

Mycophenolic acid  

Mycophenolic acid is an antimetabolite initially developed for organ transplantation that interferes with T-cell proliferation. Some reports show beneficial effects in psoriasis patients. Many patients achieve long remissions, but it may take up to 12 weeks to see maximal effects. As an immunosuppressant, there is a small risk of developing lymphoproliferative disease and non-cutaneous malignancies. In patients receiving this drug with other immunosuppressants, pure red cell aplasia has been reported. It is avoided in pregnant and breastfeeding women.

Retinoid  

Retinoid modulates epidermal differentiation and proliferation and possesses anti-inflammatory and immunomodulatory properties.  

Acitretin is the oral retinoid of choice. It is an effective systemic agent that is not immunosuppressive. It may be used as monotherapy for pustular, erythrodermic, and moderate-severe plaque psoriasis. Its beneficial effect occurs much more slowly when used for plaque and guttate psoriasis but improves dramatically when combined with PUVA and UVB (lower doses of agents are required). It may be combined with Calcipotriene, UVB, PUVA, and biologic agents.  

Retinoids are highly teratogenic and tend to persist in body tissues; hence, female patients should not become pregnant for 3 years after treatment has been discontinued. It should likewise be avoided in patients taking excessive amounts of vitamin A and in breastfeeding women. Mucocutaneous side effects and dyslipidemia may also occur. 

Sulfasalazine  

Sulfasalazine is useful in moderate-severe plaque-type psoriasis. Its effects are less than other systemic agents. Side effects are common but are not severe and are typically reversible.

Tofacitinib  

Tofacitinib interrupts the Janus kinase/signal transducers and transcription signaling pathway activators for cytokine activation. It may be considered for the treatment of moderate-severe psoriasis. Multiple phase III clinical trials showed a 75% reduction in PASI score at week 16 as compared to the placebo, with treatment benefits experienced up to 2 years.  

Nasopharyngitis was the most common side effect, while serious infections (cellulitis, herpes zoster, urinary tract infection, pneumonia), malignancies (lymphoma, lung cancer, breast cancer), lymphocytopenia, and dyslipidemia were also reported.

Other Systemic Treatments (Alternative Medicine)

Examples: Fish oil (omega-3 oil), curcumin  

Fish oil may be considered an adjunctive treatment option to topical, oral, and phototherapy in chronic plaque psoriasis. Oral curcumin supplements may be used as an adjunctive treatment for psoriasis patients with varying severity.

Biologic Therapy

Biologic therapy is considered for patients who have moderate to severe disease. Severe disease is defined as having a PASI score of ≥10 and a DLQI of >10. Very severe disease is quantified as having a total PASI score of ≥20 and DLQI of >18.  

In addition to the severity of the disease, the patient should also have one of the following clinical conditions:

• At high risk or has developed clinically significant drug-related toxicity and alternative standard therapy cannot be utilized
• Has contraindications to, intolerance or inaccessibility to, and/or failure to respond to phototherapy and standard systemic therapy (eg Methotrexate and Ciclosporin)
• Severe, unstable, life-threatening disease or severe localized psoriasis with significant impairment of function and/or high levels of distress
• Psoriatic arthritis making the patient eligible for anti-tumor necrosis factor (anti-TNF) agent therapy 

Biologic therapy may be offered as first-line therapy to adults who meet the criteria for biological therapy. A tumor necrosis factor (TNF) inhibitor or an interleukin (IL)-17 antagonist (except Brodalumab) may be offered as a first-line therapy to patients with both psoriasis and psoriatic arthritis. Biologic therapy must be administered continuously without interruption to prevent recurrence.   

Changing to an alternative therapy, including another biologic agent, can be considered if the patient does not meet the minimum response criteria, is initially responsive but loses response, or if biologic therapy becomes intolerable or contraindicated. One may consider dose escalation or interval reduction if with an inadequate response to the first biologic therapy due to insufficient drug exposure.  

It is important to assess patients for cancer risk and infection prior to and during biologic therapy and monitor for adverse effects during and after biologic therapy.

Anti-TNF-alpha  

Adalimumab  

Adalimumab is a human anti-TNF-alpha monoclonal antibody that is indicated in patients with moderate-severe chronic plaque psoriasis who are candidates for phototherapy or systemic therapy. It is the recommended monotherapy for patients with moderate to severe plaque psoriasis affecting the nails, palms, and soles (palmoplantar psoriasis), and it may be a treatment option for those affecting the scalp. It may also be considered in patients with erythrodermic or pustular psoriasis and chronic plaque psoriasis. It is considered appropriate for long-term continuous use. Studies showed that 80% of patients achieved 75% improvement in the PASI score at week 12.  

In order to increase the efficacy of treatment of moderate to severe plaque psoriasis, a combination with Methotrexate, topical agents (eg corticosteroids with or without vitamin D analogues), or narrowband UV phototherapy may be considered. A combination with Acitretin, Apremilast, or Ciclosporin may also be considered. Lastly, rebound does not usually occur when discontinued but it may lose efficacy after reinitiation.  

Certolizumab pegol  

Certolizumab pegol is a recombinant, pegylated, humanized Fab fragment of an anti-TNF-alpha monoclonal antibody that is indicated in adult patients with moderate-severe plaque psoriasis. Three-year efficacy data pooled from CIMPASI-1 and CIMPASI-2 phase 3 clinical trials (after initial 48-week endpoint) showed a sustained and durable response in patients dosed at 200 mg or 400 mg every 2 weeks demonstrating long-term therapeutic benefits. It may be used as a first-line biologic agent in women planning a pregnancy or when systemic therapy is needed during pregnancy. In the CRIB study, no minimal placental transfer from mother to infant was noted, suggesting lack of fetal exposure, thus supporting continuation of treatment during pregnancy when needed. No to minimal Certolizumab pegol was detected in breastmilk as demonstrated in the CRADLE study, thus treatment may be continued during breastfeeding. While the risk of harm to pregnancy or unborn infant from exposure to Certolizumab pegol cannot be completely ruled out, evidence gathered through pharmacovigilance reporting suggests that maternal exposure during the first trimester does not appear to increase the risk of adverse neonatal outcomes or major congenital malformations.  

Etanercept  

Etanercept is indicated in patients with moderate-severe plaque psoriasis. It is a recommended monotherapy for patients with moderate-severe plaque psoriasis affecting the scalp or nails and may be a treatment option in patients with inverse, erythrodermic, or pustular psoriasis. The response is maintained for up to 24 weeks in patients with severe chronic plaque psoriasis. Disease clearance may be improved when combined with Methotrexate or NB UVB phototherapy.  

Etanercept is considered in patients who are unresponsive, intolerant, or have contraindications to other systemic therapies, or where a short half-life is essential. It is a human recombinant TNF receptor p75 fusion protein that inhibits TNF. Combination with Acitretin, topical agents (eg corticosteroids with or without vitamin D analogues), Apremilast, or Ciclosporin may be a treatment option to increase efficacy in the treatment of moderate-severe plaque psoriasis.  

Infliximab  

Infliximab is indicated in patients with moderate-severe plaque psoriasis. It may be a treatment option for patients with moderate-severe plaque psoriasis affecting the nails, palms, soles (palmoplantar psoriasis), and scalp. It may also be considered in erythrodermic, inverse, or pustular psoriasis.  

Infliximab is considered for patients with very severe disease or when other biologic agents cannot be used or have failed, or where weight-based dosing is important. Infliximab is a human murine chimeric monoclonal antibody that inhibits TNF. It has high binding affinity and specificity for TNF-alpha. It has a rapid clinical response and is highly effective in initial exposure and in severe acute flares.  

Combination with Methotrexate or topical agents (eg corticosteroids with or without vitamin D analogues) may be a treatment option to increase efficacy in the treatment of moderate-severe plaque psoriasis. Combination with Acitretin or Apremilast may be considered to increase efficacy in the treatment of moderate-severe plaque psoriasis. It has variable efficacy after restarting or beyond the first year of continuous use.  

IL-12/23 Inhibitor  

Ustekinumab  

Ustekinumab is indicated in patients with moderate-severe plaque-type psoriasis. It may be a treatment option for patients with moderate-severe plaque psoriasis affecting nails, palms, and soles (palmoplantar psoriasis). It may be considered in patients with moderate-severe plaque psoriasis affecting the scalp or with erythrodermic or pustular psoriasis. It is considered in patients who are unresponsive, intolerant, or have contraindications to other systemic therapies. It is a human monoclonal antibody that targets IL-12 and IL-23 on the p40 subunit. It may be combined with Acitretin, Methotrexate, or narrowband UV phototherapy to increase efficacy in the treatment of moderate-severe plaque psoriasis in adults. Combination with topical agents (eg corticosteroids with or without vitamin D analogues), Apremilast or Ciclosporin may be considered to increase the efficacy in the treatment of moderate-severe plaque psoriasis.  

IL-17 Inhibitors  

Bimekizumab  

Bimekizumab is a humanized IgG1-kappa monoclonal antibody with 2 identical antigen binding regions that bind and neutralize IL-17A, IL-17F, and IL-17A/F cytokines. It is indicated in patients with moderate-severe chronic plaque psoriasis. Furthermore, it has been found to have superior efficacy compared to Adalimumab, Secukinumab, Ustekinumab, and placebo for moderate-severe plaque psoriasis in the BE SURE, BE RADIANT, and BE VIVID phase 3 trials, respectively. Bimekizumab given every 4 or 8 weeks showed rapid response and complete skin clearance at 16 weeks which was maintained through week 52 in the BE VIVID phase 3 trial and up to week 56 in the BE SURE and BE READY phase 3 trials with both dosing schedules. The BE RIGHT open-label extension of the BE VIVID, BE SURE, and BE READY phase 3 trials showed durability of results through maintained efficacy response of up to 4 years.  

Brodalumab  

Brodalumab is indicated in patients with moderate-severe plaque psoriasis. It may be a treatment option in adult patients with generalized pustular psoriasis. It is a human monoclonal antibody that binds to IL-17 receptor A (IL-17RA) and blocks the biologic activities of IL-17A, IL-17F, IL-17A/F, and IL-17E.  

Ixekizumab  

Ixekizumab is indicated in patients with moderate-severe plaque psoriasis. It may be a treatment option for patients with moderate-severe plaque psoriasis affecting the nails or scalp and those with erythrodermic or pustular psoriasis. It is a humanized IgG4 monoclonal antibody with neutralizing activity against IL-17A.  

Secukinumab  

Secukinumab is indicated in patients with moderate-severe plaque psoriasis. It is a recommended monotherapy in patients with moderate-severe plaque psoriasis affecting the nails or those with moderate-severe palmoplantar plaque psoriasis. It may be a treatment option in patients with moderate-severe plaque psoriasis affecting the head, neck, and scalp or in patients with moderate-severe palmoplantar pustulosis. It may also be considered an option in patients with erythrodermic psoriasis. Secukinumab is a recombinant human monoclonal antibody that binds IL-17A.

IL-23 Inhibitors  

Guselkumab  

Guselkumab is indicated in adult patients with moderate-severe plaque psoriasis. It is the recommended monotherapy in adult patients with nail, scalp, and plaque-type palmoplantar psoriasis. Guselkumab is a human IgG1 lambda monoclonal antibody that blocks p19 subunit of IL-23. It has been found to have a better response in patients with an inadequate response to treatment with Ustekinumab.  

Risankizumab  

Risankizumab is indicated in patients with moderate-severe plaque psoriasis. It is a humanized IgG1 monoclonal antibody that selectively binds to the human IL-23 cytokine's p19 subunit and inhibits its interaction with the IL-23 receptor.  

Tildrakizumab  

Tildrakizumab is indicated in patients with moderate-severe plaque psoriasis. It is a humanized IgG1 kappa monoclonal antibody that selectively blocks IL-23 by binding to the p19 subunit.  

Other Biologic Therapies  

Alefacept  

Alefacept was previously indicated in adult patients with moderate-severe plaque psoriasis candidates for phototherapy or systemic therapy but is no longer marketed.  

Efalizumab  

Efalizumab was previously indicated in patients with moderate-severe chronic plaque psoriasis but is no longer marketed due to reports of progressive multifocal leukoencephalopathy.  

Itolizumab  

Itolizumab is indicated in patients with active moderate to severe chronic plaque psoriasis who are candidates for systemic therapy. Clinical trials have shown favorable clinical effects and safety profile with monotherapy in patients with moderate to severe plaque psoriasis who failed to respond to conventional systemic therapies. It is a monoclonal antibody against T cell costimulatory CD6, it has immunomodulatory and anti-inflammatory effects.  

Spesolimab  

Spesolimab is indicated for the treatment of generalized pustular psoriasis flares in adults. It is a humanized IgG1 monoclinal antibody that binds to IL-36 receptor thereby inhibiting IL-36 signaling and preventing proinflammatory and profibrotic pathway activation.

Nonpharmacological

Patient Education

Patient and family education is the key to successful management. The patient should understand that psoriasis isa chronic disease and treatment will only control the symptoms but not cure it. Assure the patient that psoriasis is quite common and not contagious.

Discuss various therapeutic options, risks and benefits, side effects, and expected results. Emphasize theimportance of adherence to treatment. Discuss the possible exacerbating factors such as medications (eg beta-blockers, Lithium, and antimalarials) and bacterial or viral infections.

Encourage a healthy lifestyle including regular exercise, maintenance of ideal body weight (BMI of 18.5-24.9kg/m²), non-to-mild alcohol consumption, smoking cessation, and gluten-free diet (may benefit patients with psoriasis with confirmed celiac disease).

Patients with any type of psoriasis should be informed of a potentially increased risk of coronary artery disease. Advise patients to follow up yearly, especially for the first 10 years from the initial diagnosis.

Alternative Treatments

Stress reduction techniques (ie meditation), cognitive behavioral therapy, and guided imagery as adjunctive therapy may help improve psoriasis severity. Hypnosis as a therapeutic adjunct for mild-moderate psoriasis may be considered in highly hypnotizable patients who are willing to undergo this process. For patients with mild-moderate or chronic plaque psoriasis who are interested in acupuncture, this may be considered as an adjunctive treatment depending on availability and patient preference. 

Phototherapy or Photochemotherapy

Phototherapy is generally used in patients with moderate-severe psoriasis, with psoriasis in vulnerable areas that are unresponsive to topical therapy or other mitigating symptoms are present or in patients who do not wish to receive conventional systemic or biologic therapy. Phototherapy is safe and efficacious without the potent adverse effects of systemic and immunosuppressive therapies. The choice of phototherapy modality is based on the availability, efficacy, safety, and ease of therapy. It is usually given 3 times a week during the treatment phase then tapered to the lowest frequency needed to maintain symptom improvement. Review the patient’s medical history and review systems to verify that the patient does not have photosensitive diseases or medications (eg history of ionizing radiation). Phototherapy is contraindicated in patients with a history of melanoma or extensive non-melanoma skin cancer.  
 
Lubricants and emollients are needed for the efficacy of phototherapy.  If possible, sunblock should be applied to unaffected skin. Advise patients to protect the breast, ocular, and genital areas during phototherapy sessions. Absolute contraindications to phototherapy or photochemotherapy include photogenodermatoses (eg Bloom syndrome, Cockayne syndrome, Rothmund-Thomson syndrome, trichothiodystrophy, xeroderma pigmentosum), disorders with genetic predisposition to skin cancers (eg albinism, Gorlin syndrome), concomitant oral immunosuppressive medications (eg Azathioprine, Ciclosporin, Mycophenolate mofetil, Tacrolimus), and being medically unfit and unable to stand safely (eg severe cardiovascular disease or respiratory disease, poorly controlled epilepsy). 

Broadband Ultraviolet B (BB UVB)  

BB UVB is typically used in failed topical treatment, chronic stable plaque psoriasis, or guttate psoriasis. It is considered inferior in efficacy to topical PUVA monotherapy, and to narrowband UVB and oral PUVA monotherapy for generalized plaque psoriasis in adults.  

The most effective spectrum of UVB phototherapy in psoriasis is 290-320 nm. It takes an average of 20 to 25 treatments to induce clearance and is given 3 to 5 days per week.  

Clear emollients (eg petrolatum or mineral oil) improve the optical properties of the skin and should be applied prior to UVB treatment. UVB plus topical or systemic treatments can achieve more effective results and have a faster onset. It may also be combined with topical vitamin D analogues (after UV exposure), topical coal tar, PUVA, topical retinoid, low cumulative dose of systemic Methotrexate, or low dose of oral retinoids (eg Acitretin for generalized plaque psoriasis in adults).  

The short-term adverse reactions include erythema, itching, burning, and stinging, while the long-term adverse effects include photoaging and dermatoheliosis.

Narrowband Ultraviolet B (NB UVB)  

NB UVB consists of utilizing a UV light spectrum of around 311 nm. It is recommended for patients with >50% baseline disease severity 3 months after treatment, in patients at high risk for skin cancer, and as monotherapy for plaque psoriasis in adults and guttate psoriasis irrespective of age. It is recommended for patients with an inadequate response to topical therapy or when topical therapy is not suitable before considering systemic immunosuppression or immunomodulation therapies including PUVA. It is recommended as a short-term rescue therapy to manage flares in patients undergoing systemic therapy (eg Acitretin, Apremilast, biologic agents, Fumaric acid ester agents, Methotrexate).

It is considered superior to BB UVB but not as effective as PUVA. It is recommended over BB UVB monotherapy for generalized plaque psoriasis in adults. Though less effective than PUVA, NB UVB appears to be safer, more convenient, and less costly than PUVA.  

It takes an average of 15-30 treatments to induce clearance and is given 2-3 times per week. It is more effective than BB UVB with clearance within 2 weeks of treatment.  

It may be combined with oral retinoids or Apremilast in patients with generalized plaque psoriasis who had an inadequate response to monotherapy. Concomitant topical treatment with corticosteroids, retinoids, and vitamin D analogues can be used safely.  

The short-term adverse reaction includes burning while the long-term adverse effect is an increased risk for skin cancer.

Oral Psoralen Plus UVA (PUVA)  

Oral PUVA is recommended for adult psoriasis. Psoralen is usually taken orally 90-120 minutes prior to administration of UVA radiation.  

Short-term monotherapy is more effective than NB UVB for adult psoriasis. It is highly effective in the treatment of moderate-severe plaque, guttate-pattern psoriasis that cannot be controlled by topical therapy and with the potential for long remissions.  

Up to 90% of patients achieve improvement or clearing of plaques after 20-30 treatments and it is given 2-3 times per week.

Patients must wear protective eye gear and sunscreens must be used throughout the day due to the photosensitizing effect of psoralens.  

PUVA with topical or systemic treatments can achieve more effective results and have a faster onset. It may be combined with a low dose of oral retinoids, systemic Methotrexate (only for very severe psoriasis), vitamin D analogues, topical retinoids, topical steroids, or UVB.  

The short-term adverse reactions include erythema, irregular pigmentation, xerosis, pruritus, and nausea or vomiting while the long-term adverse effects include cutaneous malignancies (eg squamous cell carcinoma and possible melanoma) which are usually dependent on the cumulative dose, increased risk of photodamage, and lentigines. Lifetime exposure should be limited to 200 PUVA sessions to minimize the risk of cancers. 

Soak or Bath PUVA  

Soak or bath PUVA is recommended in adults with moderate-severe plaque psoriasis.  

Soak PUVA is used in patients with localized palmoplantar psoriasis prior to UVA exposure.  

Bath PUVA is safe and effective for the treatment of patients with generalized stable plaque psoriasis. It has a lower UVA cumulative dose and fewer adverse effects and drug interactions when compared to oral PUVA, hence, it may be preferred by some patients over oral PUVA. It may be an alternative in patients with generalized psoriasis who cannot tolerate oral psoralens.

Topical PUVA phototherapy is superior to localized NB UVB in adults with localized plaque psoriasis, especially palmoplantar psoriasis and palmoplantar pustular psoriasis.

Psoriasis_Management