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 severity of psoriasis by taking into account 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. 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. 

The severity of the disease based on BSA is graded as follows:

• 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, inflammatory bowel disease, 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 choice of therapy in managing psoriasis should be individualized based on the severity of the disease, the presence of comorbidities, and healthcare services access. Most patients will undergo multiple simultaneous therapies. The clinician should become familiar with all the treatment options so that the right therapy can be chosen for each individual patient. 

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 biological 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. 

The treatment goals include a targeted final outcome of PASI of ≤2, PGA clear or almost clear, or DLQI of <2. The treatment response is achieved if the patient attains ≥75% improvement from the baseline PASI score. 

The assessment of treatment success for fast-acting drugs may be started after induction therapy up until 16 weeks (24 weeks for slow-acting drugs) after initiating treatment. The assessment during maintenance therapy is usually every 8 to 12 weeks or in intervals following safety monitoring recommendations. 

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, inflammatory bowel disease, 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 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 biological therapy beyond 16 weeks gestation. 

Pharmacological therapy 

Topical Therapy

Topical therapy is considered the first-line treatment for mild plaque psoriasis.  

Emollients*

Emollients are considered the standard adjunctive therapeutic approach to the treatment of psoriasis. It is 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. 

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. 

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

Calcineurin Inhibitors

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. 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. 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 of lesions, and steroid potency and formulation. For the scalp, lotions, sprays, solutions, 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, are only mildly effective.  

A flare-up of psoriasis may occur upon discontinuation; hence, corticosteroid therapy should be reduced slowly.

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. 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 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.

Tars*  

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.  

*Many 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. They inhibit keratinocyte proliferation and enhance keratinocyte differentiation, after binding to vitamin D receptors.  

Tacalcitol or Calcipotriene combined with steroids may be considered in patients with facial psoriasis. 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-biological Therapy

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, 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, with palmoplantar pustulosis, need systemic therapy but have plans to have children in the future, and had treatment failure after Methotrexate therapy or has 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). 

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. 

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 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 biological 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.

Immunosuppressive or Biological Therapy

Immunosuppressive or biological therapy is considered for patients who have 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 

Immunosuppressive or biological 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.  

Changing to an alternative therapy, including another biological agent, can be considered if the patient does not meet the minimum response criteria, is initially responsive but loses response, or if biological 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 biological therapy and monitor for adverse effects during and after biological therapy.

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-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-severe plaque psoriasis, a combination with Methotrexate, topical agents (eg corticosteroids with or without vitamin D analogues), or narrow band UV phototherapy may be considered. A combination with Acitretin, Apremilast, or Ciclosporin may also be considered.  

Rebound does not usually occur when discontinued but it may lose efficacy after reinitiation.

Alefacept  

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

Brodalumab  

Brodalumab 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. It is indicated in adult patients with moderate-severe plaque psoriasis who are candidates for phototherapy or systemic therapy and unresponsive or lost response to other systemic agents. It may be a treatment option in adult patients with generalized pustular psoriasis.  

Certolizumab  

Certolizumab 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 who are candidates for phototherapy or systemic therapy. It may be used as a first-line biologic agent in women planning a pregnancy or when systemic therapy is needed during the second or third trimester. 

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.  

Etanercept  

Etanercept is a human recombinant TNF receptor p75 fusion protein that inhibits TNF and is indicated in patients with moderate-severe plaque psoriasis. It is the 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.  

It is considered in patients who are unresponsive, intolerant, or have contraindications to other systemic therapies, or where a short half-life is essential. 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.  

Guselkumab  

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

Infliximab  

Infliximab is a human murine chimeric monoclonal antibody that inhibits TNF. It has high binding affinity and specificity for TNF-alpha. It 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. 

Consider Infliximab for patients with very severe disease or when other biologic agents cannot be used or have failed, or where weight-based dosing is important. 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. 

Ixekizumab  

Ixekizumab is a humanized IgG4 monoclonal antibody with neutralizing activity against IL-17A. It is indicated in patients with moderate-severe plaque psoriasis who are candidates for phototherapy or systemic therapy. 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.  

Risankizumab  

Risankizumab 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. It is indicated in patients with moderate-severe plaque psoriasis who are candidates for phototherapy or systemic therapy.  

Secukinumab  

Secukinumab is a recombinant human monoclonal antibody that binds IL-17A. It is indicated in patients with moderate-severe plaque psoriasis who are candidates for phototherapy or systemic therapy. It is the 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.  

Tildrakizumab  

Tildrakizumab is a humanized IgG1 monoclonal antibody that selectively blocks IL-23 by binding to the p19 subunit. It is indicated in patients with moderate-severe plaque psoriasis who are candidates for phototherapy or systemic therapy.  

Ustekinumab  

Ustekinumab is a human monoclonal antibody that targets IL-12 and IL-23 on the p40 subunit. It 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.  

Studies showed 67% of patients achieved 75% improvement in the PASI score at week 12.    

It may be combined with Acitretin, Methotrexate, or narrow band 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. 

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. 

Other Therapy: 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 if other mitigating symptoms are present. 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).  

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. Phototherapy is safe and efficacious without the potent adverse effects of systemic and immunosuppressive therapies. 

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 Psoralen plus Ultraviolet A (PUVA) monotherapy, and to narrow band UVB and oral PUVA monotherapy for generalized plaque psoriasis in adults.  

The most effective spectrum of UVB phototherapy in psoriasis is 300 to 313 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.

Narrow Band 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 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 to 30 treatments to induce clearance and is given 2 to 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.

Psoralen Plus UVA (PUVA)  

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

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

308-nm Excimer Laser and Excimer Light  

Three hundred and eight nanometer excimer laser and excimer light are recommended for localized mild-moderate plaque psoriasis involving <10% BSA, including palmoplantar psoriasis. They may also be used in patients with extensive disease or for individual lesions. The excimer laser is more effective than excimer light for adults with localized plaque psoriasis and is recommended for adults with scalp psoriasis.  

An average of 10 to 12 treatments are needed to induce clearance and are given 2 to 3 times per week. Patients may be in remission for up to 2 years. The excimer laser may be combined with topical corticosteroids in adult patients with plaque psoriasis.  

They specifically target the affected skin and spare the uninvolved skin using a reduced cumulative dose thereby decreasing the long-term risk of malignancy. Common side effects with lower doses are erythema and hyperpigmentation while erosions, blistering, and crusting may occur with higher doses.

Other Phototherapy Modalities  

Pulsed dye laser may be considered for patients with nail psoriasis. Evidence is sufficient to support the use of climatotherapy and Goeckerman therapy for psoriasis treatment.