---

Psoriasis - Comprehensive Management Across All Systems of Medicine

---

1. OVERVIEW AND DEFINITION

• Affects 1-2% of the population worldwide
• Two peak age ranges: 16-22 years and 57-60 years
• Genetic: 50% risk if both parents affected; ~16% if one parent affected
• Strong HLA-Cw6 association in early-onset disease

---

2. CLINICAL TYPES

---

3. PATHOGENESIS (KEY MECHANISMS)

• Dendritic cells produce IL-23, which drives Th17 cell differentiation
• Th17 cells produce IL-17, promoting neutrophil-predominant inflammation and keratinocyte activation
• TNF-alpha augments IL-17's effects on keratinocytes and is coproduced by dermal DCs
• Keratinocytes show markedly reduced basal cell transit times, abnormal differentiation, and increased production of antimicrobial peptides and inflammatory mediators
• Koebner phenomenon (isomorphic response): psoriatic lesions appear at sites of trivial skin trauma
• Auspitz sign: pinpoint bleeding on scale removal (dilated capillary loops reaching just under the epidermis - "squirting papillae")

---

4. CLINICAL SIGNS

• Auspitz sign: bleeding points when scale is removed
• Koebner phenomenon: lesions at sites of trauma
• Grattage sign: candle-grease scale on scraping
• Scales: micaceous, looser peripherally, adherent centrally
• Nail changes: random pitting (proximal matrix), oil spots (distal matrix), onycholysis, subungual hyperkeratosis

---

5. MANAGEMENT - ALLOPATHY (CONVENTIONAL MEDICINE)

A. TOPICAL THERAPY (Mild/Localized Disease)

• Most frequently prescribed therapy for localized psoriasis
• Class I (ultra-potent, e.g., clobetasol) for 2-week courses; 68-89% of patients achieve clear improvement
• Weekend pulse therapy to reduce local side effects (atrophy, striae, telangiectasia)
• Low-to-medium potency for face and intertriginous areas
• Intralesional triamcinolone acetonide (2.5-10 mg/mL) for refractory plaques and nail psoriasis
• AVOID systemic steroids - withdrawal can precipitate life-threatening generalized pustular psoriasis

• Calcipotriene (calcipotriol): Comparable efficacy to clobetasol; inhibits keratinocyte proliferation and promotes differentiation
• Combination calcipotriene + corticosteroid has increased efficacy and fewer side effects (SOR: A evidence)

• Tazarotene: RAR-specific retinoid; modulates keratinocyte differentiation and suppresses inflammation; often combined with topical corticosteroid to reduce irritation

• Crude coal tar, liquor carbonis detergens (LCD), tar bath oils, shampoos; anti-inflammatory and antiproliferative
• Less cosmetically acceptable but effective for scalp and body; basis of Goeckerman technique

• Short-contact anthralin treatment (SCAT): applied 15-30 minutes then washed off
• Mechanism: suppresses neutrophil superoxide generation, inhibits IL-6, IL-8, TNF-alpha in monocytes

• Tacrolimus 0.1% ointment and pimecrolimus: especially for thin lesions on face and intertriginous areas (inverse psoriasis); avoids steroid atrophy (SOR: B evidence)

• Salicylic acid: keratolytic in shampoos, creams, gels; promotes absorption of other agents; risk of salicylate toxicity with widespread use

• Roflumilast (Zoryve) 0.3% cream: PDE4 inhibitor; approved for plaque psoriasis ages 6+; 72% PASI 50, 40% PASI 75 at 8 weeks in DERMIS-1/-2 trials
• Propylene glycol-free, suitable for sensitive patients

---

B. PHOTOTHERAPY (Moderate/Widespread Disease)

• Peak emission 311 nm; most commonly used; cost-effective
• Effective even for moderate-to-severe disease; better safety profile than PUVA
• Clearing at wavelengths 296-313 nm; maintenance therapy prolongs remission

• Used less frequently; doses titrated to MED (minimal erythema dose)

• 8-methoxypsoralen (8-MOP) taken orally 2 hours before high-intensity UVA, twice weekly
• Most patients clear in 20-25 treatments; very effective even for severe psoriasis
• Risks: cataracts (protective eyewear mandatory), squamous cell carcinoma (dose-related), melanoma risk, photoaging
• Alternatives: bath PUVA (psoralen dissolved in bathwater)

• 2-5% tar applied to skin + tar bath + UVB exposure; patients clear in ~18 days average
• 75% remain disease-free for extended periods; effective even in biologic-refractory patients

• Coal tar bath + UV + anthralin paste daily; effective regimen

• Targeted UVB for localized plaques; fewer total treatments needed

---

C. SYSTEMIC THERAPY (Moderate-to-Severe Disease)

• Gold standard systemic agent; folic acid antagonist
• Indications: erythrodermic psoriasis, psoriatic arthritis, acute pustular psoriasis (von Zumbusch), widespread BSA involvement
• Dose: 5-30 mg/week (oral or SC); three divided doses 12 hours apart or single weekly dose
• Folic acid supplementation reduces side effects (nausea, mucositis)
• Pre-treatment: LFTs, renal function, hepatitis serology, HIV, TB test, CBC
• Monitoring: weekly CBC and monthly LFTs initially; liver biopsy controversial but considered in psoriasis

• Calcineurin inhibitor; rapid onset of action (weeks)
• Not suitable for sustained long-term therapy (nephrotoxicity, hypertension)
• Useful for rapid control of severe flares

• Systemic retinoid for widespread, palmoplantar, or pustular psoriasis
• Not effective as monotherapy for plaque psoriasis but excellent for pustular and erythrodermic types
• Combined with phototherapy (Re-PUVA); requires 3 years of contraception post-treatment in women

• Oral PDE4 inhibitor; approved for all types of psoriasis (mild-severe); now also pediatric indication (age 6+, >20 kg)
• No laboratory monitoring required; useful as add-on or when biologics are contraindicated
• Can be combined with other systemics due to unique MOA

• Tofacitinib, deucravacitinib: effective for plaque and nail psoriasis
• Side effects: dose-dependent decreases in RBC, transient neutropenia; monitor CBC

---

D. BIOLOGIC THERAPY (Moderate-to-Severe Refractory Disease)

• Produce "dramatic responses at dramatic expense"
• IL-17 and IL-23 inhibitors currently show the highest PASI 90/100 response rates
• TNF inhibitors are preferred when psoriatic arthritis co-exists
• Screen for TB, hepatitis B, and latent infections before starting
• Monitor for opportunistic infections, demyelinating disease (TNF-i)
• Contraindicated in active serious infections, uncontrolled CHF, active TB

---

E. COMBINATION THERAPY

• Methotrexate + infliximab: reduces neutralizing antibody formation
• Re-PUVA (acitretin + PUVA): reduces total UVA dose needed
• Biologic + topical agents: to minimize systemic dose
• Methotrexate + acitretin: for severe generalized pustular psoriasis

---

F. TREATMENT OF SPECIAL SITUATIONS

---

6. AYURVEDA (TRADITIONAL INDIAN MEDICINE)

• Panchakarma: Vamana (emesis), Virechana (purgation), Basti (enema), Raktamokshana (bloodletting)
• Raktamokshana (leech therapy / Jalaukavacharana): local application of leeches to affected areas; reduces local inflammation and systemic humoral imbalance

• Turmeric (Haridra / Curcuma longa): topical paste and oral; anti-inflammatory via curcumin
• Neem (Azadirachta indica): Nimba - antipruritic, antimicrobial; internal and topical
• Guduchi (Tinospora cordifolia): immunomodulator
• Khadira (Acacia catechu): blood purifier; used in skin diseases
• Wrightia tinctoria (Darsana): used in Daivya oil preparation; shown anti-psoriatic activity
• Indukantha Ghrita, Mahatiktaka Ghrita: classical formulations for skin diseases

• Avoid incompatible foods (Viruddha ahara), excessive salty/sour/heavy foods
• Favor bitter, astringent tastes; light, easily digestible foods
• Avoid seafood, curd, alcohol, and dairy in excess

---

7. UNANI MEDICINE

• Taleeq (Leech Therapy): two leeches applied over affected sites twice weekly for ~10 sittings; a 2025 case report showed significant reduction in PASI and DLQI scores after 35 days, with improved quality of life and no adverse effects
• Zimad (Topical paste): anti-inflammatory herbal pastes applied locally
• Dalk (Massage): medicated oil massage
• Hammam (medicated steam bath): detoxification and skin penetration of medicaments
• Idrar-e-bol (diuretics) and Mushil (laxatives): humoral purification
• Herbal formulations: Sumbul, Barg-e-Neem, Chaksu, Suranjan, and other herbs with anti-inflammatory/immunomodulatory action

---

8. HOMEOPATHY

---

9. NATUROPATHY

• A 2025 systematic review (PMID 39987781) found Mediterranean diet, calorie restriction, and gluten-free diet (in gluten-sensitive patients) reduce PASI scores
• Anti-inflammatory diet: omega-3 fatty acids (fish oil), polyphenol-rich fruits and vegetables
• Elimination of: alcohol, processed foods, high-glycemic foods, red meat

• Warm/cold alternating water therapy to stimulate circulation
• Dead Sea salt baths (balneotherapy): reduces scaling and inflammation; supports remission
• Spa/climatotherapy at Dead Sea or sulphur springs

• Short supervised fasts may reduce inflammatory load
• Colonic irrigation (with caution)

• Omega-3 fatty acids (EPA/DHA): reduce leukotriene B4 levels; anti-inflammatory
• Vitamin D3: deficiency linked to psoriasis severity
• Zinc: reduces inflammation; supports skin healing
• Probiotics: gut microbiome modulation; reduces systemic inflammation
• Aloe vera gel: topical soothing and anti-inflammatory

• Meditation, yoga, pranayama: stress is a major trigger; reduces cortisol-driven immune dysregulation
• Mindfulness-based stress reduction (MBSR): shown in clinical studies to reduce subjective psoriasis severity

---

10. HERBAL MEDICINE (Evidence Summary)

---

11. LIFESTYLE AND TRIGGER AVOIDANCE (ALL SYSTEMS)

• Avoid triggers: streptococcal infections (treat promptly), stress, smoking, alcohol, NSAIDs, beta-blockers, lithium, antimalarials, systemic steroid withdrawal
• Moisturizers: regular emollient use reduces flares and improves QOL
• Sun exposure: moderate sunlight often beneficial (except severe erythrodermic cases)
• Weight management: obesity worsens psoriasis; weight loss improves biologic response
• Smoking cessation: strongly associated with psoriasis severity
• Stress management: yoga, meditation, psychotherapy

---

12. INTEGRATIVE APPROACH - TREATMENT ALGORITHM

MILD (PASI < 10, BSA < 10%)
├── Topical corticosteroids (Class I-III)
├── Calcipotriol ± corticosteroid combination
├── Tazarotene / Roflumilast
└── Adjunct: Ayurvedic topicals, moisturizers, naturopathy diet

MODERATE (PASI 10-20, BSA 10-30%)
├── NB-UVB phototherapy
├── PUVA (for palmoplantar or thick plaques)
├── Apremilast (oral, no labs needed)
└── Adjunct: Panchakarma, herbal supplements, dietary changes

SEVERE (PASI > 20, BSA > 30%, or affecting QOL significantly)
├── Methotrexate (standard; with folic acid)
├── Cyclosporine (rapid response needed)
├── Acitretin (pustular/erythrodermic)
├── Biologics: TNF-i → IL-23 inhibitors → IL-17 inhibitors
├── JAK inhibitors (tofacitinib, deucravacitinib)
└── Integrative: stress reduction, Mediterranean diet, omega-3s

SPECIAL:
├── Psoriatic arthritis → TNF-i biologics (first-line biologic)
├── HIV → ART first; avoid biologics or use with extreme caution
└── Pregnancy → Topicals, NB-UVB, prednisone (impetigo herpetiformis)

---

13. KEY RECENT EVIDENCE (2024-2025)

• [PMID 39987781] (2025): Mediterranean diet and calorie restriction have the strongest dietary evidence for psoriasis improvement
• [PMID 40210174] (2025): Indigo naturalis, Mahonia aquifolium, and aloe vera show best herbal evidence
• [PMID 39080843] (2024): Systemic review on guttate psoriasis - antibiotics for strep-triggered cases, NB-UVB effective
• [PMID 40856907] (2025): Biologics (especially IL-17 and IL-23 inhibitors) are most effective for erythrodermic psoriasis
• Latest 2025 conventional options: Roflumilast 0.3% topical, expanded apremilast indications (all severities, pediatric 6+), deucravacitinib (TYK2 inhibitor) showing excellent PASI 75/90 without immunosuppression

---