Numerous topical and systemic therapies are available for the treatment of psoriasis. Treatment modalities are chosen on the basis of disease severity, relevant comorbidities, patient preference (including cost and convenience), efficacy, and evaluation of individual patient response.
Psychosocial aspects
Psoriasis can have negative psychosocial effects. Clinicians should address the psychosocial needs of patients with psoriasis. The National Psoriasis Foundation provides extensive resources to help patients with psychosocial problems and to educate patients on their treatment options.
●Limited plaque psoriasis:
•We suggest that patients with limited plaque psoriasis be initially treated with topical corticosteroids and emollients (Grade 2B).
•Alternatives include tar, topical retinoids (tazarotene), topical vitamin D, and anthralin. For facial or intertriginous areas, topical tacrolimus or pimecrolimus may be used as alternatives or as corticosteroid-sparing agents.
•Improvement can be anticipated within one or two months. Combination regimens may be required, including localized phototherapy. Patient adherence may be the largest barrier to treatment success with topical therapies; early follow-up (one week after starting treatment) may improve compliance.
●Moderate to severe plaque psoriasis:
•We suggest that most patients with moderate to severe plaque psoriasis be initially treated with phototherapy if feasible and practical (Grade 2B). Financial considerations or time constraints may make systemic therapy preferable to phototherapy for some patients.
•Topical therapies are generally also required as adjuvant therapy and for symptomatic relief. (See ‘Topical therapies’ above.)
•In patients with contraindications to phototherapy or who have failed phototherapy, we suggest treatment with a systemic agent (Grade 2B). Systemic agents include retinoids, methotrexate, cyclosporine, apremilast, biologic immune modifying agents, and deucravacitinib.
•Improvement from phototherapy or systemic therapies should be observed within weeks. Patients on systemic treatment will generally require care by a dermatologist.
