Therapeutic Modalities for

Psoriasis:
Topical, Systemic, and
Phototherapy

Tutor Name: Nancy Naguib

Author Name: Rene Browne
Module:1
Word Count:1060
 Content

Introduction…………………………………………………………………………………....... 3

Topical Therapy…………………………………………………………………………………. 4

Systemic Therapy………………………………………………………………………………... 5

Phototherapy……………………………………………………………………………………. 6

Conclusion………………………………………………………………………………………...7

References……………………………………………………………………………………… 8-10

Appendix…………………………………………………………………………………… 11-14

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 Introduction

Psoriasis, a chronic inflammatory skin condition, affects millions globally, making it a

significant health concern. Over 7.4 million people in the USA and 125 million worldwide,
approximately 2-3% of the global population, suffer from this condition, according to the
International Federation of Psoriasis Associations. Psoriasis is typically characterized by well-
demarcated erythematous scaly plaques, which can be itchy and painful and vary in color from
dark brown to purple (Chiang & Verbov, 2020). Plaque psoriasis accounts for most cases while
other types are named based on the areas they affect, such as the nails, scalp, inverse regions, or
the characteristics of the lesions, such as guttate psoriasis.
The management of psoriasis involves various therapeutic approaches, including topical
treatments, systemic therapies, and phototherapy. Each modality has its own approach and has
specific indications, benefits, adverse effects, and contraindications, which will be explored in
this essay.

Topical Therapy

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Topical treatments are essential in managing mild to moderate psoriasis due to their localized
effects and minimal systemic absorption. Common topical agents include corticosteroids,
vitamin D analogues, and retinoids, along with others like calcineurin inhibitors, coal tar, and
anthralin (Weiss, 2024). These treatments offer effective symptom control with relatively fewer
systemic side effects, making them a first-line choice in many cases.

Corticosteroids are the most frequently used topical agents for psoriasis, available in low,
moderate, and high-potency forms. Low-potency options, such as hydrocortisone, are suitable for
sensitive areas like the face, while high-potency options like clobetasol are reserved for more
resistant cases (Medscape, 2024). While these agents are highly effective in reducing
inflammation and slowing rapid skin cell turnover, prolonged use can lead to side effects such as
skin atrophy, striae, telangiectasia, and acne exacerbation (American Academy of Dermatology,
2024). Topical corticosteroids are contraindicated in cases of untreated bacterial, fungal, or viral
skin infections, skin atrophy, and hypersensitivity.

Vitamin D analogues such as calcipotriol regulate skin cell production, making them effective
for chronic plaque psoriasis. Although generally safe, they can cause local irritation and rarely
lead to hypercalcemia if used over large areas (American Academy of Dermatology, 2024). They
should not be used in patients with hypercalcemia, vitamin D toxicity, or in sensitive areas such
as the face due to the risk of irritation.

Topical retinoids like tazarotene are used to reduce scaling and plaque thickness by normalizing
skin cell growth. However, this treatment can cause irritation, dryness, and increased sun
sensitivity. These agents are contraindicated during pregnancy and in cases of eczema or
photosensitivity.

Systemic Therapy

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Systemic treatments are specifically used to manage moderate to severe psoriasis cases, mainly
when topical and phototherapy are inadequate. These therapies can affect the entire body and are
usually used when psoriasis significantly impacts an individual's quality of life.

Methotrexate is a widely used systemic agent for severe psoriasis. It is particularly effective in
cases where other treatments have failed. This drug is administered in weekly doses ranging from
10-25 mg (Medscape, 2024); methotrexate reduces the rapid growth of skin cells and
inflammation, which occurs in cases of psoriasis. It is generally well-tolerated and can be
prescribed on a long-term basis. However, it does produce a series of side effects, such as liver
toxicity, bone marrow suppression, and gastrointestinal disturbances. It should be contraindicated
in patients with liver disease, pregnancy, blood disorders, or those with active infections.

Cyclosporine is a potent immunosuppressant used to treat severe psoriasis. By inhibiting T-cell

activation, cyclosporine can rapidly reduce symptoms. Clinical trials show improvement in up to
90% of patients within 12-16 weeks (Flohr et al.,2023). This drug can be nephrotoxic and cause
many other side effects; as such, it is typically prescribed for short-term use, with a treatment
duration of 3-6 months. It is contraindicated in patients with compromised immune systems,
renal impairment, hypertension, or a history of cancer.

Biologics, derived from living organisms, represent a more targeted approach to treating
moderate to severe psoriasis. Entarecept, Infliximab, adalimumab, Certolizumab, etc., explicitly
target psoriasis's immune pathways. Biologics are particularly effective for patients with
psoriasis and psoriatic arthritis and have shown significant improvement in symptoms, with
many achieving nearly clear skin (American Academy of Dermatology, 2024). However,
biologics carry a risk of infection, and their use is contraindicated in patients with active or latent
infections, a history of cancer, or immune system disorders such as HIV.

Although systemic therapies are highly effective, their adverse effects can be severe, including
immunosuppression, increased risk of cardiovascular disease, liver and kidney damage, and even
cancer. Patients should be carefully selected, and proper monitoring should be done when
considering this type of therapy.

Phototherapy

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Phototherapy is an established treatment for moderate to severe psoriasis, mainly when topical
therapies are insufficient. This approach uses specific wavelengths of light to slow the excessive
skin cell growth seen in psoriasis and reduce inflammation.

UVB phototherapy is the most commonly used form of light therapy and comes in two
varieties: broadband and narrowband UVB. Narrowband UVB, in particular, is preferred because
it is more effective and less likely to cause skin damage. This treatment is effective for plaque
psoriasis and other types, such as scalp and nail psoriasis (American Academy of Dermatology,
2024).

PUVA therapy, a combination of UVA light and a drug called psoralen, is used for more severe
cases of psoriasis. PUVA enhances the skin’s sensitivity to UVA light, improving treatment
efficacy and increasing the risk of side effects such as sunburn. Long-term use may cause skin
cancer.

Targeted phototherapy involves laser technology, which helps deliver UV light specifically to
affected areas, sparing healthy skin. This is useful for patients with localized psoriasis resistant to
topical treatments.

Phototherapy is highly effective when combined with other treatments; it also carries risks, such
as erythema, pruritus, fast rate of skin ageing and cancer if this therapy is used for an extended
period. This therapy is contraindicated in patients with a history of skin cancer or those with
photosensitivity disorders.

Conclusion

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In conclusion, the treatment of psoriasis involves a multifaceted approach tailored to the severity
and type of the disease and the individual patient’s needs. Topical treatments are the first line for
mild cases, while systemic therapies and phototherapy are reserved for more severe or treatment-
resistant forms. Each treatment modality has its own set of benefits, adverse effects, and
contraindications, requiring careful consideration by healthcare professionals to ensure the best
outcomes for patients.

References

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1. American Academy of Dermatology (2024a). Psoriasis treatment: Biologics. Available

at: https://www.aad.org/public/diseases/psoriasis/treatment/medications/biologics

(Accessed: 11 October 2024).

2. American Academy of Dermatology (2024b). Psoriasis treatment: Phototherapy.

Available at: https://www.aad.org/public/diseases/psoriasis/treatment/medications/

phototherapy (Accessed: 11 October 2024).

3. Chiang, N.Y.Z. and Verbov, J. (2020). Dermatology: A handbook for medical students

and junior doctors. 3rd ed. London: British Association of Dermatologists. (pp.50–51)

4. Dresden, D. (2023). What to know about light therapy for psoriasis. Medical News

Today. Available at: https://www.medicalnewstoday.com/articles/323593 (Accessed: 11

October 2024).

5. Feldman, S.R. and Soung, J. (2024). Chronic plaque psoriasis in adults: Treatment of

disease requiring phototherapy or systemic therapy. UpToDate. Available at:

https://www.uptodate.com/contents/chronic-plaque-psoriasis-in-adults-treatment-of-

disease-requiring-phototherapy-or-systemic-therapy (Accessed: 07 October 2024).

6. Flohr et al. (2023). ‘Efficacy and safety of ciclosporin versus methotrexate in the

treatment of severe atopic dermatitis in children and young people (TREAT): a

multicentre parallel group assessor-blinded clinical trial’. British Journal of Dermatology,

Volume 189 (pp. 674–684), https://doi.org/10.1093/bjd/ljad281 (Accessed: 14 October

2024).

7. Howell, S.T., Cardwell, L.A. and Feldman, S.R. (2018). 'A review and update of

phototherapy treatment options for psoriasis', Current Dermatology Reports, 7(3), (pp.

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 213–224). Available at: https://doi.org/10.1007/s13671-018-0211-3 (Accessed: 11

October 2024).

8. International Federation of Psoriasis Associations (IFPA) (2021) Psoriasis: A Global

Health Challenge. Available at: https://ncdalliance.org/international-federation-of-

psoriasis-associations-ifpa (Accessed: 12 October 2024).

9. Medscape (2024). Trexall, Otrexup (methotrexate) dosing, indications, interactions,

adverse effects, and more. Available at: https://reference.medscape.com/drug/trexall-

otrexup-methotrexate-34320 (Accessed: 10 October 2024).

10. Menter, A. et al. (2019).'Joint AAD-NPF guidelines of care for the management and

treatment of psoriasis with biologics', Journal of the American Academy of Dermatology,

80(4), (pp. 1029-1072). Available at: https://doi.org/10.1016/j.jaad.2018.11.057

(Accessed: 11 October 2024).

11. Nall, R. (2023). Injections to treat psoriasis: Types, benefits, and risks. Medical News

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(Accessed: 07 October 2024).

12. Ngan, V. and Vather, D. (2020) Guidelines for the management of psoriasis. DermNet.

[online]. Available at: https://dermnetnz.org/topics/guidelines-for-the-treatment-of-

psoriasis (Accessed: 11 October 2024).

13. Schreiber, A.M. and Friery, E. (2022). 'Psoriasis: Update on topical therapy from the

American Academy of Dermatology', American Family Physician. [online]. Available at:

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14. WebMD (2023) 11 biologic medications for psoriasis treatment. Available at:

https://www.webmd.com/skin-problems-and-treatments/psoriasis/biologic-medications-

psoriasis (Accessed: 11 October 2024).

15. Weiss, K. (2024). Psoriasis Treatment. Healthline. [online]. Available at:

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Appendix

https://dermnetnz.org/imagedetail/11077-chronic-plaque-psoriasis

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 Picture of Chronic Plaque psoriasis

https://dermnetnz.org/imagedetail/11052-erythrodermic-psoriasis
Erythrodermic Psoriasis

https://dermnetnz.org/imagedetail/6134-generalised-pustular-psoriasis
Pustular Psoriasis

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https://dermnetnz.org/imagedetail/17430-guttate-psoriasis
Guttate Psoriasis

https://dermnetnz.org/imagedetail/7245-flexural-psoriasis
Inverse or Flexural Psoriasis

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 https://dermnetnz.org/imagedetail/17472-nail-psoriasis

Nail Psoriasis

https://dermnetnz.org/imagedetail/2492-scalp-psoriasis
Scalp Psoriasis

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https://dermnetnz.org/imagedetail/7242-psoriatic-arthritis
Psoriatic Arthritis

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