Treatment for psoriasis is stratified by disease severity, with topical therapies as first-line for mild disease and systemic agents or phototherapy for moderate-to-severe disease.
Mild psoriasis:
Topical corticosteroids combined with vitamin D analogues are first-line treatment for mild to moderate psoriasis, with combination therapy demonstrating superior efficacy compared to either agent alone.
For scalp involvement, calcipotriene foam or calcipotriene/betamethasone dipropionate gel should be used for 4-12 weeks.
Additional topical options include calcineurin inhibitors (tacrolimus, pimecrolimus) for facial and intertriginous areas to avoid skin atrophy, and tazarotene, which can be combined with medium- or high-potency corticosteroids.
Once lesions are quiescent, proactive maintenance therapy with twice-weekly application reduces recurrence risk.
Moderate-to-Severe Psoriasis
Systemic therapy is generally considered when body surface area exceeds 5%.
Narrowband UVB phototherapy is effective for plaques and diffuse guttate psoriasis not responding to topical treatments.
Oral systemic options include:
Methotrexate: If no 25% reduction in psoriasis area and severity Index occurs after 4 weeks, switching to another systemic treatment is recommended
Ciclosporin: Fast-acting for severe disease or crisis management.
Acitretin: Normalizes keratinocyte proliferation, useful for pustular and palmoplantar variants.
Apremilast: Phosphodiesterase-4 inhibitor approved for moderate-to-severe psoriasis and psoriatic arthritis.
Deucravacitinib: Tyk2 inhibitor for moderate-to-severe disease.
Biologic therapies targeting TNF, IL-17, IL-23, and IL-12/23 have demonstrated high efficacy for both cutaneous and systemic inflammation.
All patients should be screened for metabolic syndrome, as treatment decreases psoriasis severity.
Early screening for psoriatic arthritis and proactive cardiovascular risk reduction are crucial for optimizing long-term outcomes.