A 60-year-old woman is evaluated for follow-up treatment of long-standing psoriasis. Medical history is significant for hypertension and hypercholesterolemia. Family history includes multiple family members with psoriasis. She has no joint symptoms, and her medications are atenolol and simvastatin.
On physical examination, vital signs are normal. There is no joint swelling.
She has a total of 30% body surface area involvement with psoriasis without nail involvement.
Which of the following is the most appropriate treatment?
B. Oral prednisone
C. Tacrolimus ointment
D. Topical calcitriol
MKSAP Answer and Critique
The correct answer is A. Methotrexate. This content is available to MKSAP 18 subscribers as Question 9 in the Dermatology section. More information about MKSAP is available online.
This patient has moderate to severe psoriasis (30% or more body surface area involvement) and should be treated with systemic agents. Patients with psoriasis covering more than 10% body surface area or those with psoriatic arthritis, recalcitrant palmoplantar psoriasis, pustular psoriasis, or psoriasis in challenging anatomic areas (groin, scalp) may be considered for systemic therapy. These include tumor necrosis factor inhibitors, acitretin, methotrexate, IL-23 and IL-17 inhibitors, and phototherapy. Tumor necrosis factor inhibitors, such as etanercept, adalimumab, and infliximab, are excellent options for treating patients with both severe psoriasis and psoriatic arthritis. The newer IL-12/IL-23 and IL-17 inhibitors have shown excellent efficacy in psoriasis treatment. Therapy with any of the systemic agents should be guided by a clinician experienced in their use, including appropriate evaluation for contraindications and careful monitoring.
Prednisone is not a good choice for the treatment of psoriasis, as the doses of prednisone required would lead to numerous side effects. Prednisone also has been shown to cause pustular and erythrodermic flares in a subset of patients with psoriasis. Oral glucocorticoids should also be avoided because they may worsen associated comorbidities such as hypertension and dyslipidemia.
Topical medications such as vitamin D analogues (for example, calcitriol), immunomodulators, and glucocorticoids can be used for the treatment of psoriasis; however, they are best used as solo agents in the treatment of mild disease with less than 10% body surface area involvement. These medications are often employed in conjunction with systemic therapy to treat small areas of psoriasis that remain after treatment with a systemic agent. Topical immunomodulators, pimecrolimus cream, or tacrolimus ointment are best used on the face or in intertriginous regions to avoid the atrophy seen with topical glucocorticoids.
- Moderate to severe psoriasis is best treated with systemic agents; avoid prednisone as a therapy for psoriasis.