Psoriasis Treatment Options

The primary aims when treating psoriasis are:

1. Reduce skin inflammation and slow the overproduction of skin cells.
2. Clear or reduce plaques/squamation (the scaly surface) to improve appearance, reduce itching or discomfort, and restore normal skin.
3. Maintain remission and prevent flare-ups.
4. Minimize side effects and risks of therapy.

Given the range of disease severity, a step-wise approach to treatments is often taken, starting with milder options and escalating if needed.

Therapies for psoriasis generally fall into these main categories: topical, phototherapy, systemic (oral or injected), and lifestyle / adjunctive measures.

Topical Treatments

For mild psoriasis (small plaques, limited body area), topical therapies are first-line. Common topical options include:

• Corticosteroids (steroids)
• Non-steroidal alternatives (calcineurin inhibitors, PDE4 inhibitor, aryl hydrocarbon receptor agonist, vitamin D analogue, retinoids, and keratolytics)

Topical therapy is typically safe, but overuse (especially of high potency steroids) may lead to skin thinning, irritation, or systemic absorption.

If topical therapy alone is insufficient, or disease is more widespread, additional treatments are considered.

Phototherapy

When topical treatments don’t suffice, light therapy (particularly narrowband UVB) is commonly considered a next step.  This treatment can be highly effective and very safe, but the requirement of multiple weekly sessions in an office is burdensome and not possible for most patients.

Systemic Therapies (Non-targeted)

For moderate to severe psoriasis (large area, resistant to topicals/phototherapy, or associated joint disease), systemic therapies are used. Prior to the advent of biologics and other targeted therapies over the past two decades, systemic agents were broadly immunosuppressive and had the potential for significant side effects, requiring careful monitoring of blood tests. Medications that were once commonplace for the treatment of psoriasis, such as methotrexate, cyclosporine, and acitretin, are rarely used today.

Biologic and Targeted Therapies

The most significant advances in psoriasis treatment have come from biologic and targeted small molecule therapies, which work in a much more targeted action on the specific immune pathways that drive psoriasis.

Biologics (Injectable)

Biologics are proteins (often monoclonal antibodies) that block specific immune molecules (cytokines) or cell-surface receptors. These medications are injected into the skin every few weeks to months. They can be divided based on molecules that they target:

• TNF-α inhibitors (etanercept, adalimumab, infliximab) were the first biologic class approved for psoriasis.
• IL-12 / IL-23 inhibitor (ustekinumab)
• IL-17 inhibitors (secukinumab, ixekizumab, brodalumab, bimekizumab)
• IL-23 inhibitors (e.g. guselkumab, risankizumab, tildrakizumab)

These biologics often achieve very high levels of skin clearance, with many patients even having complete clearance of their psoriasis.

Small Molecule Inhibitors (Oral)

• PDE4 inhibitor (apremilast)
• TYK2 inhibitor (deucravacitinib)

Which treatment is appropriate depends on:

1. Severity and extent of disease: mild, moderate, or severe (often judged by body surface area, involvement of sensitive sites, symptoms)
2. Location of plaques: some areas (face, genitals, nails) require gentler approaches or combinations.
3. Patient factors: age, comorbid medical conditions (liver disease, kidney disease, infections), pregnancy plans, preference for oral vs injectable, monitoring capacity.
4. Prior treatments and responses: switching therapies is common.
5. Cost, access, insurance coverage: unfortunately, insurance coverage can sometimes dictate choices given that the newer medications often come with very high price tags
6. Monitoring and safety considerations: immunosuppression risks, lab monitoring, screening for infections (e.g. tuberculosis, hepatitis) before biologics.