The document discusses various treatment options for psoriasis, ranging from topical therapies to phototherapy and systemic medications. Topical therapies include corticosteroids, vitamin D analogues, coal tar, retinoids, calcineurin inhibitors, dithranol, and salicylic acid. Phototherapy options are UVB, NB-UVB, and PUVA. Systemic medications mentioned for moderate to severe cases include methotrexate, retinoids, cyclosporine, and biologic immune modifying agents such as TNF inhibitors and IL inhibitors. Side effects, administration, and efficacy of the different treatment options are also covered.

2. The goal is to reach minimal or no skin involvement with a well-
tolerated treatment regimen.
The acceptable response for plaque psoriasis after 3 months of
treatment:
1. <3% body surface area (BSA) involvement or
2. 75% improvement
The target response after 6 months ≤1% BSA.

3. Psychosocial aspects
Psoriasis is a frustrating disease.
be empathetic and spend adequate time with the patient.
touch the patient when possible to prove that it is neither repulsive
nor contagious.
there is no cure for psoriasis.
Educate the patient, making it clear that the primary goal is control
the disease
Psoriasis may cause depression, counseling/treatment with
psychoactive medications.

4. Choice of therapy
1. Limited disease managed with topical agents,
2. moderate to severe disease may need phototherapy or
systemic therapy.
The disease location: psoriasis of the hand, foot, or face is
debilitating so need more aggressive treatment.
Moderate to severe psoriasis: is
1. involvement of >5-10% BSA, or
2. involvement of the face, palm or sole, or
3. disease that is otherwise disabling.
>5% BSA require phototherapy or systemic therapy
Widespread pustular disease requires aggressive treatment, (s.t.
hospitalization).

5. Limited disease
1. Corticosteroids,
2. Emollients,
3. vitamin D analogs (calcipotriene and calcitriol),
4. tar,
5. Topical retinoids (tazarotene).
6. Topical tacrolimus or pimecrolimus for facial or intertriginous
areas, as corticosteroid sparing agents.
7. Localized phototherapy.
Combinations:
Potent topical corticosteroids + calcipotriene, calcitriol, tazarotene,
or UVB phototherapy.
Calcipotriene + Class I topical corticosteroids for short-term control.
Then calcipotriene alone or with potent corticosteroids used (on
weekends) for maintenance.

6. Moderate to severe disease
1. retinoids,
2. methotrexate,
3. cyclosporine,
4. apremilast, or
5. biologic immune modifying agents.
a. anti-tumor necrosis factor (TNF) agents
i. adalimumab,
ii. etanercept,
iii. infliximab, and
iv. certolizumab pegol;
b. the anti-interleukin (IL)
i. IL12/IL-23 antibody ustekinumab
ii. IL-17 antibodies secukinumab and ixekizumab;
iii. anti-IL-17 receptor antibody brodalumab; and
iv. IL-23/IL-39 antibodies guselkumab and
tildrakizumab.

7. Topical Therapy
1. Emollients
Petroleum jelly or thick creams.
Hydration and emollients are
adjuncts to psoriasis treatment.
Minimizes the symptoms of itching
and tenderness, thus subsequent
Koebnerization.

8. Topical Therapy
2. Local Corticosteroids
anti-inflammatory, antiproliferative, and immunosuppressive actions
The efficacy/potency of a topical corticosteroid is dependent on:
1. application site,
2. plaque thickness,
3. the vehicle,
4. how well drug molecule activates corticosteroid receptors,
5. compliance.

9. Topical Therapy
2. Local Corticosteroids
●On the scalp or in the external ear canal: potent corticosteroids
solution (e.g., fluocinonide 0.05% or clobetasol propionate 0.05%).
Clobetasol 0.05% shampoo, foam, or spray.
Afro hair may prefer ointment vehicle for scalp.
●On the face and intertriginous areas: a low-potency ointment or cream
(e.g., over-the-counter hydrocortisone 1% or prescription-strength
2.5%).
●For thick plaques on extensor surfaces: potent preparations
(e.g., betamethasone 0.05% or clobetasol propionate 0.05%) are often
required.

10. Topical Therapy
2. Local Corticosteroids
Twice daily application of topical corticosteroids  rapid decrease in
inflammation
can be continued as long as the patient has thick active lesions
• Improvement: then reduce frequency
• recur quickly: then applied intermittently (such as on weekends
only)
Add topical noncorticosteroid to avoid long term daily application

11. Topical Therapy
2. Local Corticosteroids
S/E:
• Dermal atrophy
• tachyphylaxis
• relapse
• adrenal suppression

12. Topical Therapy
2. Local Corticosteroids
Brand name Generic name
CLASS 1—Superpotent
Clobex Lotion/Spray/Shampoo, 0.05% Clobetasol propionate
Cordran Tape, 0.05% Flurandrenolide
Cormax Cream/Solution, 0.05% Clobetasol propionate
Diprolene Ointment, 0.05% Betamethasone dipropionate
Olux E Foam, 0.05% Clobetasol propionate
Olux Foam, 0.05% Clobetasol propionate
Psorcon Ointment, 0.05% Diflorasone diacetate
Psorcon E Ointment, 0.05% Diflorasone diacetate
Temovate Cream/Ointment/Solution, 0.05% Clobetasol propionate
Topicort Topical Spray, 0.25% Desoximetasone
Ultravate Cream/Ointment, 0.05% Halobetasol propionate
Ultravate Lotion, 0.05% Halobetasol propionate
Vanos Cream, 0.1% Fluocinonide

13. Topical Therapy
2. Local Corticosteroids
CLASS 2—Potent
Diprolene Cream AF, 0.05% Betamethasone dipropionate
Elocon Ointment, 0.1% Mometasone furoate
Florone Ointment, 0.05% Diflorasone diacetate
Halog Ointment/Cream, 0.1% Halcinonide
Lidex Cream/Gel/Ointment, 0.05% Fluocinonide
Psorcon Cream, 0.05% Diflorasone diacetate
Topicort Cream/Ointment, 0.25% Desoximetasone
Topicort Gel, 0.05% Desoximetasone

14. Topical Therapy
2. Local Corticosteroids
CLASS 3—Upper Mid-Strength
Cutivate Ointment, 0.005% Fluticasone propionate
Lidex-E Cream, 0.05% Fluocinonide
Luxiq Foam, 0.12% Betamethasone valerate
CLASS 4—Mid-Strength
Cordran Ointment, 0.05% Flurandrenolide
Elocon Cream, 0.1% Mometasone furoate
Kenalog Cream/Spray, 0.1% Triamcinolone acetonide
Synalar Ointment, 0.03% Fluocinolone acetonide
Topicort LP Cream, 0.05% Desoximetasone
Topicort LP Ointment, 0.05% Desoximetasone
Westcort Ointment, 0.2% Hydrocortisone valerate

15. Topical Therapy
2. Local Corticosteroids
CLASS 5—Lower Mid-Strength
Capex Shampoo, 0.01% Fluocinolone acetonide
Cordran Cream/Lotion/Tape, 0.05% Flurandrenolide
Cutivate Cream/Lotion, 0.05% Fluticasone propionate
DermAtop Cream, 0.1% Prednicarbate
DesOwen Lotion, 0.05% Desonide
Locoid Cream/Lotion/Ointment/Solution,
0.1%
Hydrocortisone
Pandel Cream, 0.1% Hydrocortisone
Synalar Cream, 0.03%/0.01% Fluocinolone acetonide
Westcort Cream, 0.2% Hydrocortisone valerate

16. Topical Therapy
2. Local Corticosteroids
CLASS 6—Mild
Aclovate Cream/Ointment, 0.05% Alclometasone dipropionate
Derma-Smoothe/FS Oil, 0.01% Fluocinolone acetonide
Desonate Gel, 0.05% Desonide
Synalar Cream/Solution, 0.01% Fluocinolone acetonide
Verdeso Foam, 0.05% Desonide
CLASS 7—Least Potent
Cetacort Lotion, 0.5%/1% Hydrocortisone
Cortaid Cream/Spray/Ointment Hydrocortisone
Hytone Cream/Lotion, 1%/2.5% Hydrocortisone
Micort-HC Cream, 2%/2.5% Hydrocortisone
Nutracort Lotion, 1%/2.5% Hydrocortisone
Synacort Cream, 1%/2.5% Hydrocortisone

17. Topical Therapy
3. Vitamin D analogues
Calcipotriol, Calcitriol, and Tacalcitol for mild-moderate psoriasis,
<40% of skin
MOA: keratinocyte Vit. D receptor  (1)↓proliferation, (2) inhibit
polyamines synthesis
Reduce scale and thickness
2 daily doses. If irritating add moderate steroid in the morning
<100g/wk. Not >1y course. Not used on face or <6y of Age
Calcitriol less irritant. Tacalcitol Single night dose
Disadvantage: expensive

18. Topical Therapy
3. Vitamin D analogues
Calcipotriol is as effective as a potent steroid
Applied twice daily when used as
monotherapy
Calcipotriene + superpotent corticosteroids
(each once daily at different times of day) 
increased clinical response and tolerance
compared with either agent used alone
Skin irritation is the main adverse effect
risk of hypercalcemia is low when the drug is
used appropriately

19. Topical Therapy
3. Vitamin D analogues
Calcitriol
Also inhibits T cell proliferation and other inflammatory mediators
As effective as calcipotriol but less irritant in sensitive skin
randomized trial of 75 patients compared treatment with calcitriol 3 µg/g ointment to
calcipotriene 50 µg/g ointment for mild to moderate psoriasis on facial, hairline,
retroauricular, and flexural areas. Perilesional erythema, perilesional edema, and stinging or
burning sensations were significantly lower in the areas treated with calcitriol

20. Topical Therapy
4. Coal Tar
MOA: (1)Inhibit DNA synthesis , (2) photosensitizes skin,
(3) antiinflammatory, (4) antiproliferative.
the lesser refined the more messy/smelly but more effective
Adjunct to topical corticosteroids
Prescribed as shampoos, creams, lotions, ointments, oils, solution
and a foam.
2% or 3% crude coal tar in triamcinolone cream 0.1% applied twice
daily to individual plaques
Or 4-10% (liquor carbonis detergens, a tar distillate) in triamcinolone
cream or ointment, used similarly.
A preparation of 1% tar in a fatty-acid based lotion may be superior
to conventional 5% tar products (as effective as calcipotriene)
Tar shampoo should be left in place for 5-10 minutes before rinsing.

21. Topical Therapy
4. Coal Tar

22. Topical Therapy
5. Local Retinoids
Tazarotene
Retinoic acid receptor (RAR)  (1)↓proliferation, (2) normalize
differentiation, (3) ↓dermal inflammatory cell infiltrate
For stable chronic plague ≥20%
Used single evening dose for 12wk
0.1-0.05% gel used. If irritation reduce the strength, dose, or add
steroid
Not used <18y nor for pregnant
20 minute application followed by washing: less irritating, and have
similar efficacy
Irritation is reduced by concomitant treatment with a topical
corticosteroid

23. Topical Therapy
5. Local Retinoids
Tazarotene

24. Topical Therapy
6. Calcineurin inhibitor
Tacrolimus (0.1%), pimecrolimus (1%)
Weak, used for face, genitals, and intertriginous areas
Well tolerated but less effective compared with local steroids

25. Topical Therapy
7. Dithranol (anthralin)
MOA: (1)Inhibit DNA synthesis , (2) O2 free radical formation
Start with weak 0.1% then step up weekly interval up to 2%
Apply ≤30min daily 5days a week for a 1 month
Not for face, closed skin, avoid eye contact
Petrolatum or zinc oxide may be applied to uninvolved surrounding
skin as a protectant prior to application
Side effect: skin irritation,
permanent red-brown stains clothes and temporary purple staining
of skin  reduction of patient adherence.
Anthralin is less effective than topical vitamin D or potent topical
corticosteroid therapy

26. Topical Therapy
7. Dithranol (anthralin)

27. Topical Therapy
8. Salicylic Acid
MOA: (1) enhance penetration , (2) antiinflammatory
3-6% for first 2 days of course of treatment

28. Phototherapy
beneficial for the control of psoriatic skin lesions
MOA: anti-proliferative and anti-inflammatory effects
Modalities:
• UVB (290 to 320 nm) for extensive disease, alone or in
combination with topical tar. 3/week
• NB-UVB (311 nm) is an alternative and more effective than BBUVB
• PUVA: oral or bath psoralen followed by UVA (320 to 400 nm).
penetrates deeper into the dermis, and does not burn the skin
compared with UVB.
Methoxypsoralen ingested then UVA exposed within 2 hours.
3/week in increasing doses until remission, then 1-2/wk as a
maintenance dose
psoralen bath soaked for 15-30 minutes prior to UVA exposure
No significant difference in efficacy between PUVA and bath

29. Phototherapy
post treatment photoprotection (e.g., hat, sunscreen, goggles) to
prevent damage to skin and eyes
Gentle removal of plaques by bathing does help prior to UV exposure
Favorable features of UVB phototherapy over PUVA due to
(1) no psoralen prior to treatment and
(2) lower risk of UVB.
Home phototherapy
narrowband UVB administered via home units was as safe and
effective as office-based treatments
equipped with electronic controls
that allow only a prescribed
number of treatments.
Less costly

30. Phototherapy
Excimer laser
308 nm excimer laser considerably higher doses
results in faster responses than conventional phototherapy
After <10 treatments, 84% of patients achieved >90% clearance of
plaques. (fewer sessions compared with conventional UVB)
Side effects: temporary local tanning, erythema, and blistering
Malignancy risk
PUVA increased risk of nonmelanoma skin cancer and melanoma.
Contraindicated in history of melanoma or extensive nonmelanoma
skin cancer.

31. Phototherapy
Folate deficiency
exposure of plasma to UVA led to a 30-50% decrease in the serum
folate level within 60 minutes (only in vitro)
Saltwater baths
Exposure to natural sunlight improves psoriasis.
Bathing in sea water in combination with sun exposure
(climatotherapy) has also been used as a therapy,
use of salt water baths with artificial UV (balneophototherapy).

32. Phototherapy
Saltwater baths
no difference was found between saltwater and tap-water baths, and bath PUVA
was superior to UVB after a saltwater bath
SE of POVA: (short term) painful erythema, itch, nausea
(long term) skin ageing, CA (>1000J / 250 dose), cataract
climatotherapy

33. Phototherapy
Saltwater baths
balneophototherapy

34. Systemic Therapy
Methotrexate
folic acid antagonist
For moderate to severe cases, for psoriatic arthritis and psoriatic nail
Antiproliferative, immunosuppressive against active T cells
administered in an intermittent low-dose regimen (once weekly).
oral, iv, im, or sc; the usual dose is 7.5-25 mg /week
methotrexate can be used for long-term therapy.
{After 16 weeks methotrexate treatment, 41% patients achieved 75% improvement}
SE:
Stomatitis: prevented by concomitant folic acid 1mg/day
pulmonary toxicity,
hepatic toxicity: require monitoring
bone marrow suppression

35. Systemic Therapy
Methotrexate
Risk factors for hepatotoxicity from methotrexate include:
●alcoholic
●Persistent abnormal liver chemistry
●chronic hepatitis B or C
●Family history of inherited liver disease (eg, hemochromatosis)
●Diabetes mellitus
●Obesity
●hepatotoxic drugs
●Absence of folate supplementation
●Hyperlipidemia

36. Systemic Therapy
Methotrexate
No risk of hepatotoxicity  liver chemistries drawn every 1-3months.
Do liver biopsy if
5 of 9 AST elevated levels for 1year, or
the serum albumin level is decreased
cumulative dose of 3.5 to 4 g of methotrexate
Once patients have reached this dose, options include:
1. proceeding with a liver biopsy,
2. continuing to monitor without a liver biopsy, or
3. discontinuing methotrexate therapy.

37. Systemic Therapy
Methotrexate
For patients discontinue therapy within the first two to six months,
perform the biopsy soon after.
For patients who continue methotrexate, liver biopsies should be
considered after every 1-1.5 g of cumulative methotrexate.
patients reached this dose, options include:
1. proceeding with a liver biopsy,
2. discontinuing methotrexate, or
3. consulting with a hepatologist for further evaluation.

38. Systemic Therapy
Retinoids
vitamin A derivatives
For severe psoriasis, (pustular and
erythrodermic) or HIV associated
acitretin dose: 25 mg every other
day to 50 mg daily
can be used in combination with
UVB or PUVA therapy
Monitoring for hypertriglyceridemia and hepatotoxicity
SE: cheilitis, alopecia, and teratogenicity (prevent pregnancy
for 3y after discontinuing the drug)

39. Systemic Therapy
Cyclosporine
calcineurin inhibitor
The T cell suppressor
For severe psoriasis
Dose: 3 to 5 mg/kg per day orally
SE: renal toxicity and hypertension

40. Systemic Therapy
Apremilast
phosphodiesterase 4 inhibitor
For moderate to severe, and for P. arthritis
Costly,
{33% reach 75% improvement}
Dose: schedule 10mg/day raising 10mg everyday till 30mg x2
In renal impairment half of the dose is to be given in the morning
SE: diarrhea, nausea, upper respiratory infection, headache, weight loss,
depression, and suicidal thoughts

41. Systemic Therapy
Apremilast

42. Systemic Therapy - Biologic agents
TNF-alpha inhibitor
Etanercept
For adults with psoriatic arthritis and for patients age ≥4years with
chronic moderate to severe plaque psoriasis
Dose: s/c 50 mg 2/wk for 1st 3 months then 50 mg weekly maintenance
(pediatric: 0.8 mg/kg/wk) max 50mg/ week
{49% reach 75% clearance after 12wk}
Formation of anti-etanercept Ab in 0 -18% of patients (not lower the
efficacy of the drug)

43. Systemic Therapy - Biologic agents
TNF-alpha inhibitor
Etanercept

44. Systemic Therapy - Biologic agents
TNF-alpha inhibitor
Infliximab
For moderate to severe plaque psoriasis, well tolerated
onset of action is faster than other biologic drugs
Dose: i.v 5 mg/kg at weeks 0, 2, and 6, then every 8 weeks thereafter.
{infliximab 5 mg/kg given at weeks 0, 2, 6, 14, and 2 compared with methotrexate 15-
20mg/ week for moderate to severe psoriasis; found patients treated with infliximab
exhibited greater improvement (78% versus 42% achieved 75% improvement in the
PASI score by week 16)}
Anti-infliximab antibodies have been reported to occur in 5 to 44
percent of patients who receive infliximab for psoriasis loss of
response

45. Systemic Therapy - Biologic agents
TNF-alpha inhibitor
Adalimumab
for rheumatoid arthritis and psoriatic
arthritis
Dose: S/C 80mg then 40mg fortnightly
{40 mg fortnightly, 40 mg weekly, After 12
weeks, achieved 75% improvement in the
PASI score 53% and 80% respectively}
Ab formed in 6-50% of patients and
may reduce the response to
therapy

46. Systemic Therapy - Biologic agents
TNF-alpha inhibitor
Certolizumab pegol
pegylated humanized antibody Fab fragment with specificity for TNF-α.
for moderate to severe psoriasis, and psoriatic arthritis.
Dose: 400 mg fortnightly
minimal transfer across the placenta
does not bind the neonatal Fc receptor
because it lacks the IgG Fc.
Response rate: 75-80% reach 75%
improvement after 16wks
SE: nasopharyngitis and upper
respiratory infection.

47. Systemic Therapy - Biologic agents
anti-interleukin
Ustekinumab
Anti-IL-12 and IL-23
For moderate to severe psoriasis and psoriatic arthritis
Dose: ≤100 kg: 45 mg given at weeks 0, 4, and then every 12 weeks.
>100Kg: 90 mg in the same regimen.
Improvement: 66% reach 75% PASI after 12weeks
well tolerated
Anti-ustekinumab Ab occur in 4-6% of patients, but no prove for
affecting its efficacy.

48. Systemic Therapy - Biologic agents
anti-interleukin
Secukinumab
Anti-IL-17a monoclonal antibody
For moderate to severe plaque psoriasis
Dose: s/c 300mg/weekly at weeks 0, 1, 2, 3, and 4 then 300mg/month
{82% got 75% improvement after 12 weeks}

49. Systemic Therapy - Biologic agents
anti-interleukin
Ixekizumab
Anti-IL-17a monoclonal antibody
For moderate to severe plaque psoriasis, and psoriatic arthritis
Dose: 160 mg at week 0, then 80 mg at weeks 2, 4, 6, 8, 10, and 12, then
80 mg /month
{89% got 75% improvement after 12 weeks}
SE: transient neutropenia (12%), candidal infection (3%), and
inflammatory bowel disease (<1%)

50. Systemic Therapy - Biologic agents
anti-interleukin
Brodalumab
Anti-IL-17a monoclonal antibody
For moderate to severe plaque
psoriasis
Dose: 210 mg at weeks 0, 1, and 2 and then every two weeks
{86% got 75% improvement after 12 weeks
44% got PASI 100% compared with 22% for ustekinumab after 12 wks}
SE: suicidal ideation, Candida infections, and neutroppenia

51. Systemic Therapy - Biologic agents
anti-interleukin
Guselkumab
immunoglobulin G1 (IgG1λ) lambda
monoclonal Ab: binds to p19
subunit of IL-23. IL-39
Effective against moderate to severe and psoriatic arthritis
Dose: 100 mg at weeks 0, 4, and then every 2 months
{90% PASI after 16 weeks of treatment}
SE: Upper respiratory tract infections, tinea and herpes simplex virus
infections, arthralgia, diarrhea, and gastroenteritis

52. Systemic Therapy - Biologic agents
anti-interleukin
Tildrakizumab
immunoglobulin G1
(IgG1κ) kappa monoclonal
Ab: binds to p19 subunit of IL-23.
Effective against moderate to severe psoriasis
Dose: s/c 100 mg at weeks 0 and 4 and then every 3 months
{64% reach PASI 75 after 12 weeks of treatment}
SE: Upper respiratory tract infections, tinea and herpes simplex virus
infections, arthralgia, diarrhea, and gastroenteritis

53. Systemic Therapy - Biologic agents
Other immunosuppressive agents
Hydroxyurea,
6-thioguanine, and
Azathioprine, when other systemic
modalities cannot be used,

54. Systemic Therapy - Biologic agents
Other immunosuppressive agents
Tacrolimus, (requires larger studies).
Daclizumab, (used for prevention of renal transplant rejection),
Paclitaxel (cancer chemotherapeutic drug) under investigation for use in
severe psoriasis.
Abatacept, a drug used for psoriatic arthritis
Fumaric acid esters, reduction of psoriasis severity

55. Systemic Therapy - Biologic agents
Tonsillectomy
improvement in psoriasis after tonsillectomy
especially guttate psoriasis
Relapse after tonsillectomy is also possible.
Small molecules
Examples for the treatment of psoriasis include
molecules that block Janus kinases (JAK), lipids,
and a protein kinase C inhibitor.
• Oral tofacitinib, a small molecule JAK inhibitor
has demonstrated efficacy for moderate to
severe plaque psoriasis.

56. Systemic Therapy - Biologic agents
Small molecules
• Baricitinib, oral reversible inhibitor of JAK1/JAK2 tyrosine kinases,
with daily doses of 2, 4, 8, or 10 mg.
• Ponesimod, modulate the sphingosine 1-phosphate receptor 1
(S1PR1), a receptor involved in the movement of lymphocytes from
secondary lymphoid tissues into the circulation, may be an additional
effective method to treat psoriasis.