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Chapter 6: Psoriasis

Grace Hile; Johann Gudjonsson

PSORIASIS

Therapeutic Approach

Psoriasis is a chronic, immune-mediated skin disease that affects approximately 3% of the US population and 125 million people worldwide. Psoriasis can be categorized based on clinical presentation into plaque psoriasis, guttate, erythrodermic, pustular psoriasis, and sebopsoriasis.1 Therapy should be based on the clinical severity, and special therapeutic considerations should be given to specific subtypes, special sites of involvement such as face, hands, and genitalia, and presence or absence of comorbidities (psoriatic arthritis, obesity, cardiovascular disease, inflammatory bowel disease, and multiple sclerosis). See Table 6-1.

Table 6-1Psoriasis Treatment Table
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Table 6-1 Psoriasis Treatment Table
MEDICATION NAME INDICATIONa,b MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy
Corticosteroidsa PV Anti-inflammatory Various formulations, BID (2-4 wk for class I <50 g/wk) Skin atrophy, telangiectasia, striae, purpura None IA2,3
Vitamin D analoguesa PV Antiproliferative BID

Skin irritation

Photosensitivity

 None IA2,3
Tazarotenea PV Anti-inflammatory, anti-proliferative QD

Skin irritation

Photosensitivity

Contraindicated in pregnancy

 None IA4,5
Calcineurin inhibitors PV Anti-inflammatory Pimecrolimus 1% cream or ointment, BID Skin irritation None IB6
Anthralin   Anti-inflammatory, antiproliferative 1% cream or shampoo applied for 5-10 min QD, then increased to 20-30 min as tolerated Skin irritation, staining None IIA7
Coal tar PV Unknown Many formulations

Skin irritation

Staining of clothes

Malodor

 None IB8,9
Tapinarofa PV AHR agonist QD Skin irritation None IA10,11
P&S solution SP Antiproliferative Apply with prescription steroid to scalp under shower cap at night Skin irritation None III
Ketoconazole SP Antifungal Shampoo, apply 3× qwk, leave on for 5 min before rinsing Skin irritation None IIA12
Systemic Therapy Oral Agents
Methotrexatea PV, EP, PP, PsA, nail psoriasis Antimetabolite, folic acid antagonist Orally at 10-25 mg/wk

Hepatotoxicity, pulmonary toxicity, bone marrow suppression, nausea, vomiting, diarrhea, fatigue

Recommend oral folic acid 1-2 mg daily on all non-MTX days

 CBC, CMP, every 1-2 wk until 1 mo after goal dose, then q3-4mo IA13
Cyclosporinea PV, EP, PP, PsA, Calcineurin inhibitor 1-5 mg/kg/day Nephrotoxicity, hypertension, elevated triglyceride levels, gingival hyperplasia, hypertrichosis, tremors, hypomagnesemia, hyperkalemia, drug-drug interactions, malignancies CBC, CMP, lipid profile, magnesium, uric acid, and urinalysis wk ×2, then q2wk × 2 mo, then monthly for 6 mo, then q2mo IA14
Acitretina PV, PP, EP Synthetic retinoid, anti-proliferative ~5 mg/kg/day based on an ideal body weight

Mucocutaneous dryness, arthralgia, GI upset, photosensitivity, transaminitis hepatotoxicity, rare depression

Teratogenic

 CBC, LFT, lipid profile every month for 3 mo, then q3mo IA15
Apremilasta PV, PsA Phosphodiesterase inhibitor Orally titrated up to 30 mg BID as tolerated GI upset, fatigue, weight loss, depression None IA16
Tofacitiniba PsA JAK1 and JAK3 inhibitor 5 mg BID, or 11 mg QD Bone marrow suppression, hyperlipidemia CBC, lipids, q1mo for 3 ...

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