Version July 2025
Topical therapy, phototherapy, and systemic therapy are the major modes of treatment for chronic plaque psoriasis.
The extent and location(s) of skin involvement, complications, comorbidities, patient preference, patient ability, and treatment accessibility determine the appropriateness and feasibility of therapy.
Advantages of topical therapy include relative safety and a lack of need for specialized equipment or clinician administration.
Adjunctive daily skin moisturization with an ointment or thick cream emollient may help to reduce symptoms and maintain improvement.BSA: body surface area; IL: interleukin; NBUVB: narrowband ultraviolet B; PUVA: psoralen plus ultraviolet A; TNF: tumor necrosis factor.
* For limited body surface skin involvement that includes scalp, genital, palmar, plantar, facial, or scattered plaques, we often begin with a trial of topical therapy. However, topical treatment can be difficult, and systemic therapy and phototherapy are reasonable alternatives.
Some patients with psoriatic arthritis may require systemic therapies that are also beneficial for skin disease. Topical therapies, phototherapy, and some systemic therapies are not effective for psoriatic arthritis.
Severe symptoms or psychosocial effects may support early use of a rapidly acting systemic therapy.
¶ Topical corticosteroids are our preferred initial topical treatment because they are effective, widely available, and can be less expensive than other therapies. However, other topical therapies are reasonable alternatives (refer to Inset). In general, lower-potency corticosteroids are used for sites at greatest risk for corticosteroid-induced skin atrophy (eg, face, intertriginous, genital areas). Higher-potency corticosteroids are used for other areas. Refer to UpToDate content for details on selection of an appropriate potency and drug vehicle. Courses longer than 4 weeks may be necessary for complete clearance for some plaques responsive to this therapy. Close clinician follow-up for adverse effects is prudent. The addition of a vitamin D analog may augment efficacy but may also increase the cost or complexity of the treatment regimen. Use of a fixed combination product can reduce complexity.
Δ Refer to UpToDate content on the management of psoriasis in adults for details on topical maintenance regimens.
◊ Targeted phototherapy involves use of an ultraviolet light-emitting device (eg, excimer laser) to treat limited skin involvement. Intralesional corticosteroid injections may be beneficial for thick, chronic plaques that respond insufficiently to topical therapy.
§ The practicality of either frequent office visits or a home phototherapy unit and the presence of contraindications influence the feasibility of phototherapy. Targeted phototherapy is preferred for scalp, palmar, and plantar psoriasis. When necessary, the addition of oral acitretin may augment the response to phototherapy.
¥ PUVA photochemotherapy may be more effective than NBUVB phototherapy but is more difficult to administer and has a more severe side effect profile. Refer to UpToDate content on the administration of ultraviolet B phototherapy, targeted phototherapy, and PUVA photochemotherapy.
‡ Selection of an appropriate systemic agent involves consideration of the clinical presentation, drug characteristics, and patient preference. Refer to UpToDate content for information on how to choose a systemic agent.