General approaches to psoriasis treatment

General approaches to treatment (1)

The treatment regime is determined by the precise clinical pattern of an individual's psoriasis.

As a general rule, all treatment should be accompanied by reassurance and explanation about the non-contagious and benign nature of the complaint. The wide range of treatments should be emphasised as well as the usual life long nature of the condition.

• first-line therapy describes traditional topical therapies (such as corticosteroids, vitamin D and vitamin D analogues, dithranol and tar preparations)
  
  
• second-line therapy includes the phototherapies (broad- or narrow-band ultraviolet B light and psoralen plus UVA light [PUVA]) and systemic non-biological agents such as ciclosporin, methotrexate and acitretin
  
  
• third-line therapy refers to systemic biological therapies such as the tumour necrosis factor antagonists adalimumab, etanercept and infliximab, and the monoclonal antibody ustekinumab that targets interleukin-12 (IL-12) and IL-2

A simple regimen for the initial topical treatment of chronic plaque psoriasis can be outlined as follows (1,2):

• 1. General measures:
  • use of a soap substitute, e.g. aqueous cream, and a bath additive e.g. Polytar emollient or Balneum with Tar, and apply a moisturiser after having a bath
    
    
• 2. Topical treatment of psoriasis affecting the trunk and limbs (1,3,4)
  
  
  • initial treatment
    • a potent corticosteroid applied once daily plus vitamin D (calcitriol) or a vitamin D analogue (calcipitriol, tacalcitol) applied once daily should be offered (applied separately, one in the morning and the other in the evening) for up to 4 weeks as initial treatment for adults with trunk or limb psoriasis
      • for example betamethasone valerate 0.025% ointment once daily plus calcipotriol ointment once daily (applied separately, one in the morning and the other in the evening)
        
        
  • if once-daily application of a potent corticosteroid plus once-daily application of vitamin D or a vitamin D analogue does not result in clearance, near clearance or satisfactory control of trunk or limb psoriasis in adults after a maximum of 8 weeks, offer vitamin D (calcitriol) or a vitamin D analogue (calcipitriol, tacalcitol) alone applied twice daily
    
    
  • if twice-daily application of vitamin D or a vitamin D analogue does not result in clearance, near clearance or satisfactory control of trunk or limb psoriasis in adults after 8-12 weeks, offer either:
    • a potent corticosteroid applied twice daily for up to 4 weeks or
    • a coal tar preparation applied once or twice daily
    • if a twice-daily potent corticosteroid or coal tar preparation cannot be used or a once daily preparation would improve adherence in adults offer a combined product containing calcipotriol monohydrate and betamethasone dipropionate (e.g. dovobet ointment) applied once daily for up to 4 weeks
      
      
  • offer treatment with very potent corticosteroids in adults with trunk or limb psoriasis only:
    • in specialist settings under careful supervision
    • when other topical treatment strategies have failed
    • for a maximum period of 4 weeks
      
      
  • short-contact dithranol should be considered for treatment-resistant psoriasis of the trunk or limbs and either:
    • give educational support for self-use or
    • ensure treatment is given in a specialist setting
      
      
  • for children and young people with trunk or limb psoriasis consider either:
    • calcipotriol applied once daily (only for those over 6 years of age) or
    • a potent corticosteroid applied once daily (only for those over 1 year of age).
• 3. Topical treatment of psoriasis affecting the scalp (1,3,4)
  
  • a potent corticosteroid applied once daily should be offered for up to 4 weeks as initial treatment for people with scalp psoriasis
    • for example betnovate scalp application applied once daily for up to 4 weeks
      
    • if treatment with a potent corticosteroid does not result in clearance, near clearance or satisfactory control of scalp psoriasis after 4 weeks consider:
      • a different formulation of the potent corticosteroid (for example, a shampoo or mousse) and/or
      • topical agents to remove adherent scale (for example, agents containing salicylic acid, emollients and oils) before application of the potent corticosteroid
        • for example cocois ointment, 5% salicylic acid in emulsifying ointment
          
          
  • if the response to treatment with a potent corticosteroid for scalp psoriasis remains unsatisfactory after a further 4 weeks of treatment offer:
    • a combined product containing calcipotriol monohydrate and betamethasone dipropionate applied once daily (e.g. xamiol scalp gel) for up to 4 weeks or
    • vitamin D or a vitamin D analogue applied once daily (only in those who cannot use steroids and with mild to moderate scalp psoriasis) (e.g. calcipotriol scalp application)
      
      
  • if continuous treatment with either a combined product containing calcipotriol monohydrate and betamethasone dipropionate applied once daily or vitamin D or a vitamin D analogue applied once daily for up to 8 weeks does not result in clearance, near clearance or satisfactory control of scalp psoriasis offer
    • a very potent corticosteroid applied up to twice daily for 2 weeks for adults only or
    • coal tar applied once or twice daily or
    • referral to a specialist for additional support with topical applications and/or advice on other treatment options
      
      
  • topical vitamin D or a vitamin D analogue alone should be considered for the treatment of scalp psoriasis only in people who:
    • are intolerant of or cannot use topical corticosteroids at this site or
    • have mild to moderate scalp psoriasis
      
      
  • do not offer coal tar-based shampoos alone for the treatment of severe scalp psoriasis
• 4. Topical treatment of psoriasis affecting the face, flexures and genitals (1,3,4)
  • offer a short-term mild or moderate potency corticosteroid applied once or twice daily (for a maximum of 2 weeks) to people with psoriasis of the face, flexures or genitals e.g. hydrocortisone 1% ointment applied once or twice daily
    • corticosteroids should only be used for short-term treatment of psoriasis affecting these areas (1-2 weeks per month)
    • for adults with psoriasis of the face, flexures or genitals if the response to short-term moderate potency corticosteroids is unsatisfactory, or they require continuous treatment to maintain control and there is serious risk of local corticosteroid-induced side effects, offer a calcineurin inhibitor applied twice daily for up to 4 weeks. Calcineurin inhibitors should be initiated by healthcare professionals with expertise in treating psoriasis
    • do not use potent or very potent corticosteroids on the face, flexures or genitals

Those patients with extensive disease, who need systemic treatment, will normally be under the supervision of a consultant dermatologist, because of the potential toxicity of these drugs. The dermatologist will also be involved in the care of difficult cases where the site, or unresponsiveness of the rash, are important factors.

Phototherapy:

• conventional broad band UVB therapy and a newer narrow band UVB therapy is effective against guttate or plaque psoriasis resistant to topical therapy
• photochemotherapy (PUVA) using oral or topical psoralens is an effective and widely used treatment method (1) (2) with skin clearance rates of 50% to 75% with narrow-band UVB, and up to 85% with PUVA. (5)

Systemic therapy:

• methotrexate - used in patients with acute, generalised, pustular psoriasis, psoriatic erythroderma, psoriatic arthritis, and for extensive chronic plaque psoriasis
  • methotrexate is the first choice of systemic agent for people with psoriasis who fulfil the criteria for systemic therapy (1, 2)
• oral retinoids (acitretin)
• ciclosporin
• hydroxycarbamide (previously known as hydroxyurea) - used in instances where other second line agents have failed or are contraindicated
• fumaric acid esterase - more expensive (1)
  
  
• indications for systemic therapy include:
  • failure of adequate trial of topical therapy
  • repeated hospital admissions for topical therapy
  • extensive chronic plaque psoriasis in the elderly or infirm
  • generalised pustular or erythrodermic psoriasis
  • severe psoriatic arthropathy (1,2)

Biological interventions:

Biologicals have been transformative in the management of psoriasis, clearing widespread severe disease and improving psoriatic arthritis. They target particular steps in the immunological processes that are key to psoriasis activity.

All biologicals are effective in improving psoriasis (90% or 90% improvement in PASI compared with baseline) (6)

All biologicals are given as subcutaneous injections (patients administer themselves) except infliximab, which is given as an intravenous infusion.

There are 3 main groups: (1)

• TNF-alpha inhibitors

These include adalimumab, etanercept, infliximab, certolizumab.

If clinically needed, certolizumab may be used in pregnancy.

• Interleukin-12/23 inhibitors

These include ustekinumab, guselkumab, risankizumab, and tildrakizumab.

• Interleukin-17 inhibitors

These include secukinumab, ixekizumab and brodalumab.

In 2015 Secukinumab was approved by NICE for treatment of adults with severe plaque psoriasis that has failed to respond to systemic therapy such as ciclosporin, methotrexate and PUVA or where such treatments are contra-indicated.

NICE has now extended this recommendation to 6- to 17-year-olds with severe psoriasis where there is contra-indication to/lack of tolerance of or failure to respond to treatment, including ciclosporin, methotrexate and phototherapy. (1)

Tuberculosis screening (e.g., tuberculin skin test, interferon-gamma release assay, asking about exposure and travel history, and chest x-ray) is recommended prior to initiation of biological therapy. Screening prior to initiation also includes an HIV and hepatitis B/C test. (7)

• they are indicated when the following criteria are both met (1):
  • disease is severe as defined by a total Psoriasis Area Severity Index (PASI) of 10 or more and a Dermatology Life Quality Index (DLQI) of more than 10
  • the psoriasis has not responded to standard systemic therapies including ciclosporin, methotrexate and PUVA (psoralen and long-wave ultraviolet radiation); or the person is intolerant of, or has a contraindication to, these treatments

A consultant dermatologist should commence and monitor biological treatment methods. Patients should meet the eligibility criteria currently recommended (1, 2)

Changing to an alternative biological drug should be considered in adults if:

The psoriasis does not respond adequately to a first biological drug, the psoriasis initially responds adequately but subsequently loses this response, (secondary failure), or the first biological drug cannot be tolerated or becomes contra-indicated. (1)

Notes:

• arrange a review appointment 4 weeks after starting a new topical treatment in adults, and 2 weeks after starting a new topical treatment in children (1), to
  • evaluate tolerability, toxicity, and initial response to treatment
  • reinforce the importance of adherence when appropriate
  • reinforce the importance of a 4 week break between courses of potent/very potent corticosteroids

References:

• 1. Psoriasis: The assessment and management of psoriasis. NICE Clinical Guideline (October 2012 - last updated September 2017)
• 2. Diagnosis and management of psoriasis and psoriatic arthritis in adults. Scottish Intercollegiate Guidelines Network - SIGN (October 2010)
• 3. Bailey JW. Topical treatments for chronic plaque psoriasis. Am Family Physician. 2010 Mar 1;81(5):596.
• 4. Chiricozzi A et al. Treatment of psoriasis with topical agents: recommendations from a Tuscany consensus. Dermatol Ther. 2017 Nov;30(6).
• 5. Elmets CA et al. Joint American Academy of Dermatology – National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis with phototherapy. J Am Acad Dermatol. 2019 Sep;81(3):775-804.
• 6. Griffiths CE, Strober BE, van de Kerkhof P, et al. Comparison of ustekinumab and etanercept for moderate-to-severe psoriasis. N Engl J Med. 2010 Jan 14;362(2):118-28.
• 7. Kamata M, Tada Y. Safety of biologics in psoriasis. J Dermatol. 2018 Mar;45(3):279-86.