Treatment of psoriasis depends on the type, location, and extent of
Most cases of localized, plaque-type psoriasis can be managed
with mid-potency topical glucocorticoids, although their long-term
use is often accompanied by loss of effectiveness (tachyphylaxis)
and atrophy of the skin.
A topical vitamin D analogue (calcipotriene)
and a retinoid (tazarotene) are also efficacious in the treatment of
limited psoriasis and have largely replaced other topical agents such
as coal tar, salicylic acid, and anthralin.
Ultraviolet (UV) light, natural or artificial, is an effective therapy
for many patients with widespread psoriasis. Ultraviolet B (UVB),
narrowband UVB, and ultraviolet A (UVA) light with either oral or
topical psoralens (PUVA) are used clinically.
UV light’s immunosup-
pressive properties are thought to be responsible for its therapeutic
activity in psoriasis. It is also mutagenic, potentially leading to an
increased incidence of nonmelanoma and melanoma skin cancer.
UV-light therapy is contraindicated in patients receiving cyclospo-
rine and should be used with great care in all immunocompromised
patients due to the increased risk of skin cancer.
Various systemic agents can be used for severe, widespread pso-
riatic disease Oral glucocorticoids should not be used
for the treatment of psoriasis due to the potential for development
of life-threatening pustular psoriasis when therapy is discontinued.
Methotrexate is an effective agent, especially in patients with PsA.
The synthetic retinoid acitretin is useful, especially when immu-
nosuppression must be avoided; however, teratogenicity limits its
The evidence implicating psoriasis as a T cell–mediated disorder
has directed therapeutic efforts to immunoregulation. Cyclosporine
and other immunosuppressive agents can be very effective in the
treatment of psoriasis,
and much attention is currently directed
toward the development of biologic agents with more selective
immunosuppressive properties and better safety profiles
Experience with some of these biologic agents is limited, and infor-
mation regarding combination therapy and adverse events contin-
ues to emerge. These biologic agents appear to be quite efficacious in
treatment of psoriasis and are well tolerated;
however, caution with
certain patient comorbidities must be exercised. Use of tumor necro-
sis factor-α (TNF-α) inhibitors may worsen congestive heart failure
(CHF), and they should be used with caution in patients at risk for
or known to have CHF.
Further, none of the immunosuppressive
agents used in the treatment of psoriasis should be initiated if the
patient has a severe infection (including TB, HIV, hepatitis B or C);
patients on such therapy should be routinely screened for tuberculo-
sis. There have been reports of progressive multifocal leukoenceph-
alopathy and lupus erythematosus in association with treatment
with the TNF-α inhibitors. Malignancies, including a risk or history.
Approved Systemic Therapy for Psoriasis
AGENT MEDICATION CLASS ROUTE FREQUENCY ADVERSE EVENTS (SELECTED)
Methotrexate Antimetabolite Oral Weeklya Hepatotoxicity, pulmonary toxicity, pancytopenia, potential for increased
depression, ophthalmologic effects, pseudotumor cerebri
Cyclosporine Calcineurin inhibitor Oral Twice daily Renal dysfunction, hypertension, hyperkalemia, hyperuricemia,
hypomagnesemia, hyperlipidemia, increased risk of malignancies
type 4 inhibitor
Oral Twice dailyb Hypersensitivity reaction, depression, nausea, diarrhea, vomiting,
dyspepsia, weight loss, headache, fatigue..