Psoriasis

Background

• Psoriasis is a chronic inflammatory multisystem disease that predominantly affects the skin, nails, and/or joints.
• Psoriasis may be triggered or exacerbated by certain drugs, alcohol, infections, skin trauma, obesity, stress, cold weather, and other environmental factors.
• Patients with psoriasis may be at higher risk for psoriatic arthritis, the metabolic syndrome (obesity, hypertension, dyslipidemia, insulin resistance), psychiatric conditions (depression, anxiety), cardiovascular disease, stroke, and inflammatory bowel diseases (Crohn disease and ulcerative colitis).

Evaluation

• Psoriasis is usually diagnosed clinically based on history and physical exam.
• The most common type of psoriasis is plaque psoriasis, characterized by well-circumscribed, erythematous, flat-topped plaques with adherent silvery scale on extensor surfaces, scalp, trunk, or buttocks.
• Other types of psoriasis include:
  • Inverse (also known as intertriginous) psoriasis, characterized by erythematous plaques with minimal scale in skin folds or flexural surfaces.
  • Erythrodermic psoriasis, characterized by generalized erythema covering nearly the entire body surface with varying degrees of scaling.
  • Pustular psoriasis, characterized by localized pustules involving soles and palms occurring with or without plaque-type disease (see also Palmoplantar Pustulosis).
  • Guttate psoriasis, characterized by 1- to 10-mm pink papules with fine scale primarily on trunk and proximal extremities.
• Nail involvement may occur in up to 80% of patients with cutaneous psoriasis and is characterized by pitting, onycholysis, salmon patches, nail bed hyperkeratosis, and splinter hemorrhages.
• Psoriatic arthritis may occur in up to 25%-30% of patients with psoriasis, and appears to particularly affect the hand and foot joints, pelvis, and ribs.

Management

• Consider severity of disease and patient preferences and ability to adhere to treatment when prescribing therapy.
  • Chronic treatment for psoriasis is often needed.
  • Certain comorbid conditions, such as hepatitis, HIV, inflammatory bowel disease (Crohn disease or ulcerative colitis), malignancy, or latent tuberculosis can affect treatment selection of systemic medication options.
  • Patients should be counseled to stop smoking and limit alcohol.
• For limited plaque psoriasis on the body or scalp:
  • Advise emollients and proper skin care to restore cutaneous barrier function.
  • Offer topical corticosteroids, calcipotriene alone, or combination calcipotriene plus betamethasone dipropionate as first-line. (Strong recommendation)
  • Alternatives that may be considered include tazarotene, or tazarotene combined with topical steroid, dithranol, or coal tar.
  • For facial or intertriginous areas, consider topical tacrolimus or pimecrolimus. (Weak recommendation)
• For moderate-to-severe plaque psoriasis on the body or scalp:
  • Continue topical treatments.
  • Advise addition of 1 of the following options, depending on individual patient risks and preferences: (Strong recommendation)
    • systemic nonbiologic medications
    • biologic medications (some may be used as monotherapy)
    • narrow-band ultraviolet B (NB-UVB) (indicated for first-line treatment of generalized plaque or guttate psoriasis in pregnancy)
  • Options for systemic nonbiologic medications include:
    • methotrexate (Strong recommendation)
    • cyclosporine (Strong recommendation)
    • apremilast (Strong recommendation)
    • acitretin (Weak recommendation)
    • Janus Kinase (JAK) inhibitors (including deucravacitinib or tofacitinib [tofacitinib not FDA approved for psoriasis])
    • fumaric acid esters (not approved in the United States; Fumaderm approved in Europe)
  • Biologic medications that can reduce severity of moderate-to-severe plaque psoriasis include tumor necrosis factor (TNF) inhibitors and interleukin inhibitors.
    • Options of tumor necrosis factor inhibitors to treat psoriasis include:
      • adalimumab (Strong recommendation)
      • etanercept (Strong recommendation)
      • infliximab (Strong recommendation)
      • certolizumab
    • Options of interleukin (IL) inhibitors to treat psoriasis include:
      • ustekinumab (IL-12/IL-23 inhibitor) (Strong recommendation)
      • secukinumab (IL-17 inhibitor) (Strong recommendation)
      • ixekizumab (IL-17 inhibitor) (Strong recommendation)
      • brodalumab (IL-17 inhibitor) (Strong recommendation)
      • guselkumab (IL-23 inhibitor) (Strong recommendation)
      • tildrakizumab (IL-23 inhibitor) (Strong recommendation)
      • risankizumab (IL-23 inhibitor) (Weak recommendation)
      • bimekizumab (IL-17A/IL-17F inhibitor) (not FDA approved)
• Management of other types of psoriasis:
  • For inverse (intertriginous) psoriasis:
    • For short-term use, use a low- to midpotency topical steroid.
    • For long-term use, first-line options include:
      • calcipotriene (calcipotriol), or topical immunomodulators (pimecrolimus, tacrolimus)
      • combination therapy with low- to midpotency topical steroids plus either calcipotriene, topical tacrolimus or pimecrolimus, or antimicrobial therapy (such as topical imidazole)
    • Consider systemic medication options for moderate-to-severe disease, such as etanercept, infliximab, or ustekinumab. (Weak recommendation)
  • For erythrodermic psoriasis, consider systemic therapy with cyclosporine, infliximab, acitretin, adalimumab, etanercept, ixekizumab, secukinumab, or ustekinumab. (Weak recommendation)
  • For palmoplantar psoriasis
    • For limited disease, use superpotent topical corticosteroid.
    • For more severe palmoplantar psoriasis, options include:
      • adalimumab (Strong recommendation)
      • secukinumab (Strong recommendation)
      • guselkumab (Strong recommendation)
      • infliximab (Weak recommendation)
      • topical psoralen plus ultraviolet A (PUVA) phototherapy (Weak recommendation)
      • cyclosporine (Weak recommendation)
      • acitretin (Weak recommendation)
      • ustekinumab (Weak recommendation)
    • see Palmoplantar Pustulosis and Pustular Psoriasis of Pregnancy for additional information.
  • For guttate psoriasis, consider topical treatments and NB-UVB.
• For psoriasis in pregnancy, first-line treatment is emollients and topical steroids. If symptoms are refractory to topicals, then consider NB-UVB. If the disease is refractory to treatment with topicals and NB-UVB, consider options of TNF-alpha inhibitors, particularly certolizumab pegol, ustekinumab, and cyclosporine.
• For psoriasis in children
  • Consider topical corticosteroids, a topical vitamin D analog (for example, calcipotriene), or topical corticosteroid plus a topical vitamin D analog as first-line. (Weak recommendation)
  • For the face and genital region, consider tacrolimus 0.1% ointment. (Weak recommendation)
  • Alternative topical options include tazarotene, anthralin or coal tar preparations if available. (Weak recommendation)
  • For moderate-to-severe pediatric plaque and guttate psoriasis, consider NB-UVB phototherapy as an option. (Weak recommendation)
  • Alternatively, for moderate-to-severe pediatric psoriasis, systemic medications are an option, including:
    • etanercept for moderate-to-severe psoriasis in children ≥ 6 years old (Strong recommendation)
    • ustekinumab for adolescents ≥ 12 years old with moderate-to-severe plaque psoriasis (Strong recommendation)
    • methotrexate with weight-based dosing for moderate-to-severe plaque psoriasis and other psoriasis subtypes, including pustular psoriasis (Weak recommendation)
    • adalimumab for children and adolescents with moderate-to-severe psoriasis (Weak recommendation)
    • cyclosporine for moderate-to-severe plaque psoriasis (Weak recommendation)
    • acitretin for children with extensive guttate or moderate-to-severe (ideally thin plaque) psoriasis vulgaris (Weak recommendation)
    • fumaric acid esters considered an alternative therapy for moderate-to-severe psoriasis in pediatric patients who are candidates for systemic therapy (Weak recommendation) (not available in the United States or Canada)
    • infliximab as monotherapy or in combination with methotrexate for severe plaque or pustular psoriasis that is unresponsive to other systemic medications, rapidly progressive, unstable, and/or life-threatening (Weak recommendation)
    • ixekizumab (Taltz) FDA approved for pediatric patients ≥ 6 years old with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy