Tackling the Impossible: Psoriasis Treatment Algorithm Guided by Patients’ Preferences

The various presentations of psoriasis can make choosing from among the numerous treatment options overwhelming for patients and physicians. Treatment algorithms can help guide the decision.

Psoriasis remains one of the most common chronic inflammatory skin diseases, with worldwide prevalence ranging from 0.5% to 11.4% in adults. Psoriasis occurs in various clinical forms, including chronic plaque, guttate, pustular, erythrodermic, inverse, and nail psoriasis.1 The spectrum of manifestation ranges from asymptomatic to disabling and rarely life-threatening, with treatments ranging from observation to systemic and biologic therapy. 

The various presentations of psoriasis can make choosing from among the numerous treatment options overwhelming for patients and physicians. Treatment algorithms can help guide the decision. This article describes psoriasis treatment algorithms based not only on the severity of the disease and widely accepted guidelines, but also on patients’ preferences for efficacy, price, and safety. 

Initial Steps For All Patients 

The first step in psoriasis management is addressing patients’ psychosocial needs, including the need to understand their disease. Initial counseling starts by providing patient education materials on how to manage symptoms and increase quality of life (QoL). 

Referring patients to the National Psoriasis Foundation (NPF) provides not only basic patient education about psoriasis, but also a place for patients to connect with other patients. The American Academy of Dermatology also developed extensive 6-part guidelines on initial management of psoriasis patients. Psychosocial impact and evaluation of joints’ involvement should be a part of initial counseling. 

Screening for Psoriatic Arthritis

Psoriatic arthritis (PsA) is common in patients with psoriasis and tends to begin years after psoriasis starts. Dermatologists can screen for early PsA. Asking patients about joint stiffness, joint 

pain, or back pain is a sensitive way of identifying possible PsA. When there is suspected arthritis, physical examination should include a complete musculoskeletal examination including evaluation of range of motion and gait; x-ray evaluation of joints may also be warranted. 

Therefore, if the dermatologist is not prepared to perform such a physical examination and order the radiological examinations, a suspicion of joint involvement may merit a referral to a rheumatologist. Dermatologists and rheumatologists should collaborate in choosing the ideal treatments for patients with psoriasis and PsA. 

figure 1

Figure 1. Initial psoriasis assessment and counseling.

Categorization of Patients

The initial categorization for treatment purposes classifies patients into limited or extensive psoriasis, depending on whether or not it is feasible to apply topical treatments to all affected areas. Assessments on body surface area involvement and QoL help determine the treatment algorithm (Figure 1). 

Choosing the Therapies 

Guiding factors (Table 1) when choosing treatment modalities include treatment characteristics that affect adherence, efficacy, side effect profiles, and cost; adherence is especially important for topical treatments. 

table 1

Physicians and patients classically select treatments that strike a balance between these factors. However, patients often weigh these factors differently than the physician would. This guideline recommends medication selection guided by patients’ preference of which factor they find to be most important. As head-to-head comparisons of psoriasis treatments are sparse, this algorithm is largely opinion-based. 

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