What are general guidelines on the management and treatment of psoriasis with topical and alternative therapies, nonbiologic therapies, phototherapy, and biologic therapies?

Updated: Mar 17, 2021
  • Author: Jacquiline Habashy, DO, MSc; Chief Editor: William D James, MD  more...
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Answer

Guidelines on the management and treatment of psoriasis with topical and alternative therapies, nonbiologic therapies, phototherapy, and biologic therapies were published in February 2021 by the American Academy of Dermatology and the National Psoriasis Foundation in the Journal of the American Academy of Dermatology. [58]

Topical and alternative treatments

Topical therapies, tools to assess the severity of psoriasis, and alterative/complementary medicines are addressed, as follows:

  • Topical corticosteroids - Recommended for plaque psoriasis in nonintertriginous areas
  • Steroid-sparing agents (eg, vitamin D analogs, tazarotene, and calcineurin inhibitors, alone or in combination with steroids) - Confer lower risk of steroid-induced adverse effects; alternate use with steroids is key to long-term management
  • Other topical agents (eg, salicylic acid, emollients, anthralin, coal tar) - Can be use alone or in combination with topical steroids
  • Topicals combined with biologic or systemic therapies - Help increase overall efficacy of therapy
  • Severity measurement tools - Physician’s Global Assessment and body surface area (clinical practice); Psoriasis Area Severity Index (clinical trials); Dermatology Life Quality Index, Psoriasis Symptom Inventory, and pruritus assessment (subjective symptoms and quality of life)
  • Alternative medicines and complementary therapies (no recommendations, owing to lack of evidence) - Traditional Chinese medicine, herbal therapies (eg, aloe vera, St. John’s wort), diet/dietary supplements (eg, fish oil, vitamin D, turmeric/curcumin, zinc, gluten-free diet), body/mind interventions (eg, hypnosis, stress reduction, meditation)

Nonbiological therapies

Covered in the guideline are recommendations and efficacy and safety information on 12 oral systemic, nonbiologic medications, as follows:

  • Methotrexate - Moderate-to-severe psoriasis in adults
  • Apremilast - Moderate-to-severe psoriasis in adults
  • Cyclosporine - Severe, recalcitrant psoriasis; in addition, erythrodermic, generalized pustular psoriasis and/or palmoplantar psoriasis
  • Acitretin - Monotherapy or combination therapy with PUVA or UVB
  • Other nonbiologics (not FDA-approved for psoriasis) - Tofacitinib, hydroxyurea, mycophenolate mofetil, azathioprine, leflunomide, tacrolimus, and thioguanine

Phototherapy

The following phototherapy options are discussed in the guideline, with regard to dosing regimen, efficacy, and adverse effects:

  • Narrowband UVB
  • Broadband UVB
  • Targeted UVB - Excimer laser, excimer light, targeted narrowband UVB light
  • PUVA - Topical, oral, bath
  • Photodynamic therapy
  • Grenz ray
  • Climatotherapy
  • Visible light
  • Goeckerman therapy (not a form of phototherapy)
  • Pulsed dye laser

Biological medications

Treatment recommendations are offered on the following biologic agents, with FDA approval date in parentheses:

  • TNF inhibitors - Etanercept (4/30/2004), infliximab (9/27/2006), adalimumab (1/22/2008), certolizumab (5/27/2018)
  • IL-12/IL-23 inhibitor - Ustekinumab (9/25/2009)
  • IL-17 inhibitors - Secukinumab (1/21/2015), ixekizumab (3/22/2016), brodalumab (2/15/2017)
  • IL-23 inhibitors - Guselkumab (7/13/2017), tildrakizumab (3/21/2018), risankizumab (pending)

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