Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

plaque

1st line – topical therapies

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ONGOING
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plaque
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mild
1st line – 

topical therapies

Topical treatments are the mainstay of therapy.[52][53] 

Choice of formulation depends on the area of cover (e.g., lotion for scalp; cream for moist weeping lesions; and ointment for dry, lichenified, or scaly lesions).

For patients with limited psoriasis involvement, start with topical corticosteroids and a topical vitamin D analog.[54][55][56] [ Cochrane Clinical Answers logo ] [Evidence A] Topical calcineurin inhibitors are second-line agents. Emollients may be considered by those averse to pharmacologic options. 

Topical corticosteroid: a topical corticosteroid in combination with a vitamin D analog is more effective in treating disease than either treatment alone.[55][57] Combination therapy may help to reduce potential adverse effects associated with extensive use of topical corticosteroids. The potency of topical corticosteroid used is determined by the extent of disease and the responsiveness of the patient to medications. Low-potency treatments are appropriate for lesions on the face or intertriginous areas.[58] The combination product halobetasol/tazarotene has been approved for the treatment of plaque psoriasis in adults in some countries. 

Topical vitamin D analogs: agents such as calcipotriene bind with vitamin D-selective receptors and inhibit the hyperproliferation and abnormal differentiation of keratinocytes characteristic of psoriatic lesions.[58] Calcipotriene has a relatively slow onset of action and its maximal effect is after 6 to 8 weeks. A two-compound formulation with betamethasone dipropionate appears to be superior to other topicals in scalp psoriasis and psoriasis vulgaris.[59][60] Topical vitamin D analogs can be used alone for chronic therapy when psoriasis is under good control or when treatment needs to be applied long-term to the face or intertriginous areas. 

Topical calcineurin inhibitors: tacrolimus or pimecrolimus are often used as second-line agents in the treatment of psoriasis, especially facial, flexural, and genital psoriasis; however, this use is off-label.[61][62] 

Primary options

hydrocortisone topical: (2.5%) apply sparingly to the affected area(s) two to four times daily

or

triamcinolone topical: (0.025 or 0.1%) apply sparingly to the affected area(s) two to four times daily

or

betamethasone dipropionate topical: (0.05%) apply sparingly to the affected area(s) once or twice daily

or

clobetasol topical: (0.05%) apply sparingly to the affected area(s) twice daily for a maximum of 2 weeks, maximum 50 g/week

-- AND / OR --

calcipotriene topical: (0.005%) apply sparingly to the affected area(s) once or twice daily

OR

calcipotriene/betamethasone dipropionate topical: apply sparingly to the affected area(s) once daily for up to 4 weeks

OR

halobetasol/tazarotene topical: (0.01%/0.045%) apply sparingly to the affected area(s) once daily, maximum 50 g/week

Secondary options

tacrolimus topical: (0.1%) apply sparingly to the affected area(s) twice daily

OR

pimecrolimus topical: (1%) apply sparingly to the affected area(s) twice daily

1st line – phototherapy

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ONGOING
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plaque
|
moderate to severe
1st line – 

phototherapy

Phototherapy for moderate to severe psoriasis includes narrow-band UVB or PUVA.[65] 

Phototherapy is an effective treatment for psoriasis with skin clearance rates of 50% to 75% with narrow-band UVB, and up to 85% with PUVA.[66] 

Phototherapy requires the patient to attend the clinic or hospital several times a week for the duration of treatment.

Adverse effects of phototherapy include phototoxicity (during and after treatment), and burning if the dose is not adequately controlled. There is a small increased risk of skin cancer; the risk is higher in Fitzparick skin types I and II.

1st line – methotrexate

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ONGOING
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plaque
|
moderate to severe
1st line – 

methotrexate

A folic acid antagonist that works as an antiproliferative and anti-inflammatory agent that is considered a first-line systemic drug.

Methotrexate may increase the incidence of liver fibrosis in people who are overweight or who have diabetes.[67] 

Folic acid is usually co-prescribed with methotrexate to minimize adverse effects (such as gastrointestinal symptoms and deranged liver function tests).[68] 

Subcutaneous methotrexate may be used in people who fail to respond to oral therapy or have nausea with oral treatment.

Primary options

methotrexate: 10-25 mg orally/subcutaneously once weekly on the same day of each week

1st line – cyclosporine

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ONGOING
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plaque
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moderate to severe
1st line – 

cyclosporine

Cyclosporine suppresses T cells and pro-inflammatory cytokines (such as interleukin 2), inhibits antigen-presenting capacity of Langerhans cells, and impedes mast cell function of degranulation and cytokine production.

Cyclosporine is an effective treatment for psoriasis but has significant adverse effects, such as nephrotoxicity and hypertension.[69] It is, therefore, generally reserved for very extensive psoriasis requiring rescue to bring disease severity under relative control. 

Long-term use (i.e., >12 months) is not recommended.

Primary options

cyclosporine modified: 2.5 to 4 mg/kg/day orally given in 2 divided doses

1st line – acitretin

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ONGOING
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plaque
|
moderate to severe
1st line – 

acitretin

An oral retinoid chemically related to vitamin A that helps to regulate epithelial cell growth. Moderately effective in many cases and often combined with other treatments.

Do not use oral retinoids in women of childbearing age, as they are teratogenic.

Monitor liver function and blood lipid concentration.

Primary options

acitretin: 25-50 mg orally once daily

1st line – apremilast

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ONGOING
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plaque
|
moderate to severe
1st line – 

apremilast

An oral phosphodiesterase-4 inhibitor that works by modulating cyclic adenosine monophosphate levels, which in turn down-regulates inflammatory cytokines including tumor necrosis factor (TNF)-alpha and interleukins 23 and 17.

Clinical trials have shown apremilast to have modest efficacy in patients with moderate to severe psoriasis.[70][71][72] 

Common adverse events included nausea, diarrhea, nasopharyngitis, and upper respiratory tract infection.[70][71][72]

Apremilast should be used with caution in patients with a history of depression.

Primary options

apremilast: 10 mg orally once daily in the morning on day 1, followed by 10 mg in the morning and 10 mg in the evening on day 2, then 10 mg in the morning and 20 mg in the evening on day 3, then 20 mg in the morning and 20 mg in the evening on day 4, then 20 mg in the morning and 30 mg in the evening on day 5, then 30 mg twice daily thereafter

1st line – biologic agent

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ONGOING
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plaque
|
moderate to severe
1st line – 

biologic agent

Biologics have been transformative in the management of psoriasis, clearing widespread severe disease and improving psoriatic arthritis. They act at a cellular level and target particular steps in the immunologic processes key to psoriasis activity.

A "living" (regularly updated) Cochrane network meta-analysis has demonstrated that all biologics are effective in improving psoriasis (90% or 90% improvement in Psoriasis Area and Severity Index [PASI] compared with baseline).[77] At class level, the biologic treatments that target interleukin (IL)-17, IL-12/23, IL-23, and tumor necrosis factor (TNF)-alpha were significantly more effective than the small molecules and conventional systemic agents.[77] 

The results from another network meta-analysis of randomized controlled trials suggest that brodalumab, guselkumab, ixekizumab, and risankizumab are associated with the highest PASI response rates for both short- and long-term therapy.[78] 

Rare adverse effects include drug-induced lupus (associated with TNF-alpha inhibitors) and Candida infections (with IL‐17 inhibitors, typically mucocutaneous).[79] 

Tuberculosis screening (e.g., tuberculin skin test, interferon-gamma release assay, asking about exposure and travel history, and chest x-ray) is recommended prior to initiation of biologic therapy.[79][80] Screening prior to initiation also includes an HIV and hepatitis B/C test.[79][80] 

All biologics are given as subcutaneous injections (patients administer themselves) except infliximab, which is given as an intravenous infusion.

TNF-alpha inhibitors: these include adalimumab, etanercept, infliximab, certolizumab.[81][82][83][84][85][86][87] If clinically needed, certolizumab may be used in pregnancy. 

Interleukin-12/23 inhibitors: ustekinumab is a human monoclonal antibody that inhibits interleukins 12 and 23.[88][89][90][91] Guselkumab is a monoclonal antibody that inhibits IL-23, and is believed to provide similar health benefits to ixekizumab and secukinumab.[92][93] Risankizumab is a human monoclonal antibody that targets IL-23 and significantly improved symptoms of moderate to severe psoriasis in clinical trials.[94] Tildrakizumab is an IL-23 antagonist approved for the treatment of moderate to severe plaque psoriasis, and was efficacious when compared with placebo and etanercept in two phase 3 trials.[95] 

Interleukin-17 inhibitors: secukinumab is a human monoclonal antibody that is efficacious in clearing psoriasis plaques.[96][97][98] Ixekizumab is a monoclonal antibody; clinical trial data indicate it is highly effective in the treatment of moderate to severe psoriasis for up to 60 weeks of treatment.[99] Brodalumab is a monoclonal antibody that targets the IL-17 receptor, blocking the signaling pathway of interleukins 17A, 17F, and 25; it appears to be well tolerated and efficacious over a 2-year period.[100][101][102] 

Primary options

adalimumab: 80 mg subcutaneously on day 1, followed by 40 mg every other week starting 1 week after initial dose

OR

etanercept: 50 mg subcutaneously twice weekly for 3 months, followed by either 50 mg once weekly or 25 mg twice weekly, each dose should be 3-4 days apart

OR

infliximab: 5 mg/kg intravenously at weeks 0, 2, 6, and then every 8 weeks thereafter

OR

certolizumab pegol: 400 mg subcutaneously every 2 weeks

More

OR

ustekinumab: patient weight ≤100kg: 45 mg subcutaneously as a single dose on day 1, week 4, and week 16, then once every 12 weeks thereafter; patient weight >100kg: 90 mg subcutaneously as a single dose on day 1, week 4, and week 16, then once every 12 weeks thereafter

OR

guselkumab: 100 mg subcutaneously at weeks 0 and 4, then every 8 weeks thereafter

OR

risankizumab: 150 mg subcutaneously at weeks 0 and 4, and then every 12 weeks thereafter

OR

tildrakizumab: 100 mg subcutaneously at weeks 0 and 4, then every 12 weeks thereafter

OR

secukinumab: 300 mg subcutaneously at weeks 0, 1, 2, 3, and 4, followed by 300 mg every 4 weeks thereafter

OR

ixekizumab: 160 mg subcutaneously at week 0, followed by 80 mg at weeks 2, 4, 6, 8, 10, and 12, then 80 mg every 4 weeks thereafter

OR

brodalumab: 210 mg subcutaneously at weeks 0, 1, and 2, followed by 210 mg every 2 weeks thereafter; consider discontinuing treatment if inadequate response within 12-16 weeks

2nd line – fumaric acid esters

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ONGOING
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plaque
|
moderate to severe
2nd line – 

fumaric acid esters

Fumaric acid esters have immunosuppressive and anti-inflammatory properties.

Licensed for moderate to severe psoriasis in European countries. In the UK, dimethyl fumarate is licensed for the treatment of moderate to severe plaque psoriasis in adults.

Not approved in the US for cutaneous psoriasis but may be prescribed off-label in the US and other countries.[73][74][75][76]

Primary options

dimethyl fumarate: consult specialist for guidance on dose

1st line – cyclosporine or biologic agent

Back
ONGOING
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plaque
|
erythrodermic
1st line – 

cyclosporine or biologic agent

Patients with erythrodermic psoriasis may need admission to hospital for intense topical treatment, fluid replacement, and electrolyte monitoring. Rapid and aggressive control is essential.

Initial treatment is often with cyclosporine for around 3 weeks to manage the flare. Patients who are more stable can be started with a biologic agent (e.g., a tumor necrosis factor [TNF]-alpha inhibitor, ustekinumab).

Primary options

cyclosporine modified: 2.5 to 4 mg/kg/day orally given in 2 divided doses

Secondary options

adalimumab: 80 mg subcutaneously on day 1, followed by 40 mg every other week starting 1 week after initial dose

OR

etanercept: 50 mg subcutaneously twice weekly for 3 months, followed by either 50 mg once weekly or 25 mg twice weekly, each dose should be 3-4 days apart

OR

infliximab: 5 mg/kg intravenously at weeks 0, 2, 6, and then every 8 weeks thereafter

OR

ustekinumab: patient weight ≤100kg: 45 mg subcutaneously as a single dose on day 1, week 4, and week 16, then once every 12 weeks thereafter; patient weight >100kg: 90 mg subcutaneously as a single dose on day 1, week 4, and week 16, then once every 12 weeks thereafter

guttate

1st line – phototherapy

Back
ONGOING
|
guttate
1st line – 

phototherapy

The recommended treatment approach for guttate psoriasis largely mirrors the strategies employed for plaque psoriasis. Important differences include investigating for an infectious trigger, which may include a throat swab for streptococcal infection and a screen for HIV.

First-line treatment is phototherapy. Phototherapy for moderate to severe psoriasis includes narrow-band UVB or PUVA.[65] Phototherapy is an effective treatment for psoriasis with skin clearance rates of 50% to 75% with narrow-band UVB, and up to 85% with PUVA.[66] 

Phototherapy requires the patient to attend the clinic or hospital several times a week for the duration of treatment.

Adverse effects of phototherapy include phototoxicity (during and after treatment), and burning if the dose is not adequately controlled. There is a small increased risk of skin cancer; risk is higher in Fitzparick skin types I and II.

2nd line – cyclosporine

Back
ONGOING
|
guttate
2nd line – 

cyclosporine

Cyclosporine suppresses T cells and pro-inflammatory cytokines (such as interleukin 2), inhibits antigen-presenting capacity of Langerhans cells, and impedes mast cell function of degranulation and cytokine production.

Cyclosporine is an effective treatment for psoriasis but has significant adverse effects, such as nephrotoxicity and hypertension.[69] It is, therefore, generally reserved for very extensive psoriasis requiring rescue to bring disease severity under relative control. 

Long-term use (i.e., >12 months) is not recommended.

Primary options

cyclosporine modified: 2.5 to 4 mg/kg/day orally given in 2 divided doses

2nd line – methotrexate

Back
ONGOING
|
guttate
2nd line – 

methotrexate

A folic acid antagonist that works as an antiproliferative and anti-inflammatory agent that is considered a first-line systemic drug.

Methotrexate may increase the incidence of liver fibrosis in people who are overweight or who have diabetes.[67] 

Folic acid is usually co-prescribed with methotrexate to minimize adverse effects (such as gastrointestinal symptoms and deranged liver function tests).[68] 

Primary options

methotrexate: 10-25 mg orally/subcutaneously once weekly on the same day of each week

3rd line – acitretin

Back
ONGOING
|
guttate
3rd line – 

acitretin

An oral retinoid chemically related to vitamin A that helps to regulate epithelial cell growth. Moderately effective in many cases and often combined with other treatments.

Do not use oral retinoids in women of childbearing age, as they are teratogenic.

Monitor liver function and blood lipid concentration.

Primary options

acitretin: 25-50 mg orally once daily

pustular

1st line – supportive care, phototherapy, or systemic agents

Back
ONGOING
|
pustular
1st line – 

supportive care, phototherapy, or systemic agents

Pustular psoriasis may require hospital admission if widespread. Fluid replacement, electrolyte monitoring, and supportive care is required for patients with extensive disease.

Pustular psoriasis may be treated with intestine topical therapy, acitretin, or a combination of acitretin and phototherapy.

Other systemic agents such as methotrexate and cyclosporine may be prescribed. Cases are managed on a case-by-case basis under the supervision of a dermatologist.

Primary options

acitretin: 25-50 mg orally once daily

Secondary options

cyclosporine modified: 2.5 to 4 mg/kg/day orally given in 2 divided doses

OR

methotrexate: 10-25 mg orally/subcutaneously once weekly on the same day of each week

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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