What Should You Do First if You Suspect Psoriasis?
See a board-certified dermatologist for accurate diagnosis, as psoriasis can mimic eczema, fungal infections, and other skin conditions. A dermatologist can often diagnose psoriasis by visual examination alone but may perform a skin biopsy for confirmation. Early diagnosis and treatment reduce the risk of disease progression, joint involvement, and cardiovascular complications.
Psoriasis is frequently misdiagnosed, particularly in its early stages or when it presents in atypical locations such as the scalp, nails, or genital area. A board-certified dermatologist has the training to distinguish psoriasis from seborrheic dermatitis, nummular eczema, tinea corporis, and cutaneous T-cell lymphoma, all of which can appear similar. The American Academy of Dermatology recommends that all patients with suspected psoriasis receive a comprehensive evaluation including assessment of body surface area involvement, impact on quality of life, and screening for comorbidities.
Once diagnosed, treatment decisions depend on disease severity, location, and impact on quality of life. Mild psoriasis affecting less than 3 percent of body surface area is typically managed with topical therapies. Moderate psoriasis covering 3 to 10 percent may require phototherapy or systemic treatment. Severe psoriasis involving more than 10 percent of body surface area, or psoriasis significantly impacting quality of life regardless of extent, usually requires systemic therapy or biologics. The dermatologist should discuss all available options and develop a personalized treatment plan.
Beyond skin treatment, a comprehensive psoriasis management plan should address the systemic nature of the disease. The National Psoriasis Foundation recommends screening for psoriatic arthritis at every visit using validated tools like the PEST (Psoriasis Epidemiology Screening Tool). Cardiovascular risk assessment is important because psoriasis patients have elevated rates of myocardial infarction, stroke, and metabolic syndrome. Mental health screening for depression and anxiety should also be routine, as psoriasis significantly impacts psychological wellbeing in a large proportion of patients.
AAD guidelines recommend comprehensive evaluation including comorbidity screening for all psoriasis patients
What Are the Different Types of Psoriasis?
Plaque psoriasis is the most common type, accounting for 80 to 90 percent of cases. Other types include guttate psoriasis (small drop-like lesions triggered by strep infection), inverse psoriasis (smooth red patches in skin folds), pustular psoriasis (pus-filled blisters), and erythrodermic psoriasis (widespread redness covering most of the body, a medical emergency).
Plaque psoriasis presents as well-demarcated, raised, erythematous plaques covered with adherent silvery-white scales. These plaques most commonly appear on the elbows, knees, scalp, and lower back (sacral area), though they can develop anywhere on the body. On darker skin tones, plaques may appear darker brown or violaceous rather than pink or red, and post-inflammatory hyperpigmentation is common after plaques resolve. Scalp psoriasis affects approximately 50 percent of patients and can extend beyond the hairline onto the forehead, behind the ears, and onto the neck.
Guttate psoriasis accounts for approximately 8 percent of psoriasis cases and is characterized by numerous small (2 to 10 millimeter), drop-shaped, salmon-pink papules with fine scales scattered across the trunk, limbs, and scalp. It typically develops one to three weeks after a group A streptococcal pharyngitis infection, most commonly in children and young adults. In many cases, guttate psoriasis resolves spontaneously within three to four months, but approximately one-third of patients will develop chronic plaque psoriasis. The British Association of Dermatologists recommends checking anti-streptolysin O titers to confirm recent streptococcal infection.
Pustular and erythrodermic psoriasis are less common but more severe variants that require urgent medical attention. Generalized pustular psoriasis (von Zumbusch type) causes widespread sterile pustules with fever, malaise, and laboratory abnormalities, and can be life-threatening. Erythrodermic psoriasis involves inflammation of more than 90 percent of body surface area, disrupting thermoregulation and fluid balance. Both forms often require hospitalization and systemic treatment. The FDA recently approved spesolimab (Spevigo), an anti-interleukin-36 receptor antibody, specifically for generalized pustular psoriasis flares.
Nail psoriasis affects approximately 50 percent of patients with skin psoriasis and up to 80 percent of those with psoriatic arthritis. Characteristic findings include pitting (small depressions in the nail plate), onycholysis (separation of the nail from the nail bed), oil-drop discoloration (translucent yellow-brown patches), and subungual hyperkeratosis (thickening under the nail). Nail involvement is cosmetically distressing and can impair fine motor function. It is also a strong predictor of psoriatic arthritis development, making it clinically significant beyond its cosmetic impact.
Nail psoriasis is present in approximately 50% of skin psoriasis and 80% of psoriatic arthritis patients
What Topical Treatments Work Best for Psoriasis?
The combination of a topical corticosteroid with calcipotriol (a vitamin D analogue) is the most effective first-line topical therapy for mild-to-moderate plaque psoriasis. This combination is more effective than either agent alone. Calcipotriol-betamethasone dipropionate fixed combination (Enstilar, Taclonex) is the most studied formulation with strong evidence.
Topical corticosteroids are the most widely prescribed treatment for psoriasis and are available in seven potency classes. For body plaques, mid-to-high-potency steroids such as betamethasone dipropionate 0.05% or fluocinonide 0.05% are typically used for two to four week courses. For thinner skin areas such as the face, flexures, and genitals, low-potency steroids like hydrocortisone 1% or desonide 0.05% are preferred. The AAD recommends pulse therapy — applying potent steroids on weekdays with weekends off, or two weeks on followed by one week off — to reduce the risk of skin atrophy and tachyphylaxis.
Calcipotriol (calcipotriene in the US) is a synthetic vitamin D3 analogue that slows keratinocyte proliferation and promotes normal differentiation, directly addressing the accelerated skin cell turnover in psoriasis. It also has immunomodulatory properties. A Cochrane systematic review of 177 randomized controlled trials confirmed that the combination of calcipotriol with a potent topical corticosteroid is significantly more effective than either monotherapy for plaque psoriasis. The fixed-dose combination of calcipotriol 50 micrograms per gram with betamethasone dipropionate 0.5 milligrams per gram is available as foam (Enstilar), ointment (Taclonex), and cream formulations.
Other topical options include coal tar preparations, which have anti-inflammatory and anti-proliferative properties and have been used for psoriasis for over a century. While effective, their odor, staining properties, and messiness limit patient acceptance. Tazarotene, a topical retinoid available as 0.05% and 0.1% cream or gel, is FDA-approved for psoriasis and can be combined with corticosteroids to improve efficacy while allowing lower steroid doses. Newer topical options include roflumilast 0.3% cream (Zoryve), a PDE4 inhibitor approved in 2022 for plaque psoriasis including intertriginous areas, which provides a steroid-free alternative.
A Cochrane review of 177 RCTs confirmed calcipotriol-corticosteroid combination superiority over monotherapy
How Does Phototherapy Help Psoriasis?
Narrowband ultraviolet B (NB-UVB) phototherapy is the most commonly used and effective form of light therapy for psoriasis. It slows skin cell growth, reduces inflammation, and modulates the local immune response. Administered two to three times weekly for 12 to 24 sessions, NB-UVB can achieve clearance or near-clearance in 60 to 75 percent of patients.
Narrowband UVB phototherapy emits light at a wavelength of 311 to 313 nanometers, which penetrates the epidermis and targets the overactive T cells and dendritic cells driving psoriatic inflammation. It induces apoptosis of pathogenic T cells and promotes the generation of regulatory T cells that suppress the inflammatory cascade. Treatment is administered in a light booth at a dermatologist's office, starting at a low dose calibrated to the patient's skin type and gradually increasing. The AAD guidelines recommend NB-UVB as a first-line option for moderate-to-severe psoriasis and as an alternative to systemic therapy.
Excimer laser therapy delivers targeted NB-UVB light at 308 nanometers directly to psoriasis plaques, sparing surrounding healthy skin. This allows higher energy doses to be used, resulting in faster clearance with fewer sessions — typically eight to twelve treatments compared with twenty or more for whole-body phototherapy. The excimer laser is particularly effective for localized plaque psoriasis on the elbows, knees, and scalp. Studies in the Journal of the American Academy of Dermatology have demonstrated clearance rates of 70 to 80 percent for individual plaques with targeted phototherapy.
Home phototherapy devices have expanded access to light therapy for patients who cannot attend office-based sessions two to three times weekly. The National Psoriasis Foundation supports the use of FDA-cleared home NB-UVB units for appropriately selected patients under dermatologist supervision. A randomized pragmatic trial published in the British Medical Journal found that home phototherapy was non-inferior to outpatient phototherapy for quality of life outcomes and was significantly more convenient for patients. Insurance coverage for home units has improved in recent years but remains inconsistent across plans.
AAD guidelines recommend NB-UVB as a first-line option for moderate-to-severe plaque psoriasis
A BMJ pragmatic trial found home phototherapy non-inferior to outpatient phototherapy for quality of life
When Is Systemic Medication Needed for Psoriasis?
Systemic therapy is indicated for moderate-to-severe psoriasis covering more than 10 percent of body surface area, psoriasis significantly impacting quality of life regardless of extent, psoriasis unresponsive to topical therapies and phototherapy, and psoriatic arthritis. First-line systemic options include methotrexate, cyclosporine, and acitretin, though biologics are increasingly used as initial systemic therapy.
Methotrexate has been used for psoriasis since the 1950s and remains a widely prescribed first-line systemic agent, particularly when psoriatic arthritis is present. Administered orally or by subcutaneous injection at doses of 7.5 to 25 milligrams once weekly, methotrexate inhibits dihydrofolate reductase and has anti-inflammatory effects that suppress the overactive immune response in psoriasis. Patients must take supplemental folic acid (1 to 5 mg daily, not on the methotrexate day) to reduce side effects including nausea, mouth ulcers, and bone marrow suppression. Regular blood monitoring of complete blood count and liver function tests is mandatory.
Cyclosporine is a calcineurin inhibitor that provides rapid improvement in severe psoriasis and is often used as rescue therapy for erythrodermic or severe flares. It is typically limited to three to six month courses due to nephrotoxicity and hypertension risk with long-term use. Acitretin, an oral retinoid, is particularly effective for pustular psoriasis and can be combined with phototherapy for plaque psoriasis. It has a long half-life and is strictly contraindicated in women of childbearing potential due to teratogenicity that persists for three years after discontinuation.
Apremilast (Otezla) is an oral PDE4 inhibitor that offers a different mechanism of action with a more favorable safety profile than traditional immunosuppressants. It does not require blood monitoring and is FDA-approved for both plaque psoriasis and psoriatic arthritis. While less effective than biologics — achieving PASI 75 in approximately 30 to 40 percent of patients — it is preferred by some patients who want an oral medication without the monitoring requirements of methotrexate or the injection route of biologics. Common side effects include diarrhea and nausea, which typically resolve within the first month.
Methotrexate remains a first-line systemic therapy for moderate-to-severe psoriasis per AAD and BAD guidelines
How Are Biologics Transforming Psoriasis Treatment?
Biologic therapies have revolutionized psoriasis treatment by targeting specific immune pathways. TNF-alpha inhibitors were the first generation, followed by IL-12/23, IL-17, and IL-23 inhibitors that achieve progressively higher clearance rates. Current IL-23 inhibitors like risankizumab and guselkumab achieve PASI 90 in over 70 percent of patients with dosing as infrequent as every 8 to 12 weeks.
TNF-alpha inhibitors — etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade), and certolizumab pegol (Cimzia) — were the first biologics approved for psoriasis and remain effective options. They work by neutralizing tumor necrosis factor alpha, a pro-inflammatory cytokine that is elevated in psoriatic skin and blood. While they represented a dramatic improvement over traditional immunosuppressants, their efficacy has been surpassed by newer biologics targeting IL-17 and IL-23. Adalimumab achieves PASI 75 (75 percent improvement) in approximately 70 percent of patients, which was groundbreaking at the time of its approval.
IL-17 inhibitors — secukinumab (Cosentyx), ixekizumab (Taltz), brodalumab (Siliq), and bimekizumab (Bimzelx) — represent a major advance in psoriasis efficacy. Interleukin-17A is the key effector cytokine driving keratinocyte proliferation in psoriasis. Secukinumab and ixekizumab consistently achieve PASI 90 (90 percent improvement, essentially clear or almost clear skin) in approximately 60 to 70 percent of patients. Bimekizumab, which blocks both IL-17A and IL-17F, has shown even higher clearance rates in Phase 3 trials, with PASI 100 (complete clearance) rates exceeding 60 percent, making it one of the most effective psoriasis treatments available.
IL-23 inhibitors — guselkumab (Tremfya), risankizumab (Skyrizi), and tildrakizumab (Ilumya) — target the p19 subunit of interleukin-23, which sits upstream of IL-17 in the psoriasis inflammatory cascade. By interrupting the pathway at a higher level, these agents can achieve durable responses with remarkably convenient dosing. Risankizumab is administered by subcutaneous injection only every 12 weeks after the initial loading period and achieves PASI 90 in approximately 72 to 75 percent of patients. The extended dosing intervals, high efficacy, and favorable safety profile have positioned IL-23 inhibitors as many dermatologists' preferred first-line biologic.
Phase 3 trials show risankizumab achieves PASI 90 in 72–75% of patients with every-12-week dosing
What Is the Connection Between Psoriasis and Heart Disease?
Psoriasis is now recognized as a systemic inflammatory disease associated with significantly increased cardiovascular risk. Severe psoriasis patients have a 50 percent higher risk of cardiovascular mortality compared to the general population. The chronic systemic inflammation that drives psoriasis also accelerates atherosclerosis, and screening for cardiovascular risk factors is recommended by the AAD and National Psoriasis Foundation.
The link between psoriasis and cardiovascular disease is mediated by shared inflammatory pathways. The same cytokines elevated in psoriatic skin — TNF-alpha, IL-6, IL-17, and IL-1 beta — promote endothelial dysfunction, lipid oxidation, and plaque formation in coronary arteries. Vascular imaging studies using PET-CT and coronary CT angiography have demonstrated that psoriasis patients have greater aortic vascular inflammation and higher non-calcified coronary plaque burden than matched controls, even after adjusting for traditional cardiovascular risk factors. This subclinical atherosclerosis may explain the excess cardiovascular events observed in large epidemiological studies.
Large population-based studies, including a seminal analysis of the UK General Practice Research Database published in JAMA, have quantified this increased risk. Patients with severe psoriasis have a 58 percent increased risk of major cardiovascular events (myocardial infarction, stroke, cardiovascular death) and a higher prevalence of hypertension, diabetes, obesity, and metabolic syndrome compared to age-matched controls. Importantly, the risk is independent of traditional cardiovascular risk factors, suggesting that psoriatic inflammation itself is a cardiovascular risk factor analogous to diabetes.
Emerging evidence suggests that effective psoriasis treatment may reduce cardiovascular risk. Observational studies using coronary CT angiography have shown that one year of biologic therapy reduces coronary plaque progression in psoriasis patients. A study published in the Journal of the American Heart Association found that patients treated with TNF inhibitors had significantly lower rates of major cardiovascular events compared to those treated with topical therapy alone. While randomized trial data are still needed, these findings support aggressive psoriasis treatment as potentially cardioprotective beyond skin clearance.
A landmark JAMA study found a 58% increased risk of major cardiovascular events in severe psoriasis patients
How Can You Manage Psoriasis on the Scalp and Nails?
Scalp psoriasis is treated with medicated shampoos containing coal tar, salicylic acid, or ketoconazole, combined with topical corticosteroid solutions, foams, or sprays designed for hairy areas. Nail psoriasis is notoriously difficult to treat topically; intralesional corticosteroid injections and systemic therapies, particularly biologics, are the most effective options for nail involvement.
Scalp psoriasis affects approximately 45 to 56 percent of patients and ranges from mild fine scaling to thick adherent plaques covering the entire scalp. Treatment begins with descaling agents — salicylic acid 3 to 6% in a mineral oil or coconut oil base applied overnight under a shower cap, then washed out in the morning. Once scales are removed, topical corticosteroid solutions (clobetasol propionate 0.05% solution), foams, or sprays can penetrate more effectively. Calcipotriol-betamethasone gel is also available for scalp use and is supported by strong clinical trial evidence from the BAD guidelines.
Nail psoriasis requires patience and realistic expectations because the nail grows slowly — fingernails take six months and toenails twelve to eighteen months to fully replace. Topical treatments have limited efficacy because they cannot penetrate the nail plate effectively. Options include high-potency topical corticosteroids under occlusion, calcipotriol ointment applied to the nail folds, and tazarotene 0.1% gel. Intralesional triamcinolone acetonide injections into the nail matrix can improve pitting and nail plate dystrophy but are painful and require repeated sessions every four to six weeks.
Systemic therapies and biologics are the most effective treatments for nail psoriasis. Clinical trial data consistently show that biologics targeting IL-17 and IL-23 produce the greatest nail improvement. Ixekizumab achieved complete nail clearance (NAPSI 0) in approximately 50 percent of patients by week 60 in the UNCOVER trials. Methotrexate and cyclosporine also improve nail psoriasis but less dramatically. The AAD recommends that significant nail involvement, even in the absence of extensive skin disease, can justify systemic therapy due to the functional impairment and psychological distress nail psoriasis causes.
Ixekizumab achieved complete nail clearance in approximately 50% of patients by week 60 in UNCOVER trials
What Lifestyle Changes Help Manage Psoriasis?
Maintaining a healthy body weight, limiting alcohol consumption, quitting smoking, managing stress, and moisturizing daily can all improve psoriasis outcomes. Obesity is a significant risk factor for psoriasis severity and reduces the effectiveness of systemic treatments. The National Psoriasis Foundation recommends an anti-inflammatory dietary pattern rich in fruits, vegetables, and omega-3 fatty acids.
Obesity and psoriasis have a bidirectional relationship: obesity increases the risk of developing psoriasis, and psoriasis itself promotes weight gain through systemic inflammation, reduced physical activity, and psychological factors. Adipose tissue produces TNF-alpha, IL-6, and other pro-inflammatory cytokines that worsen psoriatic inflammation. A randomized controlled trial published in JAMA Dermatology demonstrated that a structured low-calorie diet achieving 5 to 10 percent weight loss significantly improved psoriasis severity and response to systemic therapy in overweight and obese patients. The study found a dose-response relationship between weight loss and PASI improvement.
Alcohol consumption and smoking are both independently associated with psoriasis risk and severity. Alcohol is immunosuppressive and can impair liver function, which is particularly concerning for patients taking methotrexate. Smoking doubles the risk of developing psoriasis and worsens existing disease by promoting oxidative stress and Th17-mediated inflammation. The BAD and National Psoriasis Foundation both strongly recommend smoking cessation and alcohol moderation as part of comprehensive psoriasis management. Providing referrals to smoking cessation programs should be routine in dermatology practice.
Stress management is important because psoriasis frequently flares during periods of psychological stress. The relationship is bidirectional — psoriasis causes stress, and stress worsens psoriasis. Mindfulness-based stress reduction (MBSR) has shown benefit in small clinical trials, with one study in Psychosomatic Medicine finding that psoriasis patients who listened to mindfulness meditation recordings during phototherapy cleared 3.8 times faster than those receiving phototherapy alone. Regular exercise, adequate sleep, and psychological support through therapy or peer support groups are also recommended by the National Psoriasis Foundation.
A JAMA Dermatology RCT showed that 5–10% weight loss significantly improved psoriasis severity and treatment response
What New Psoriasis Treatments Are in Development?
The psoriasis pipeline includes oral TYK2 inhibitors like deucravacitinib (Sotyktu), already FDA-approved, which offer selective JAK pathway inhibition without the boxed warnings of traditional JAK inhibitors. Bimekizumab (dual IL-17A/F inhibitor) is achieving record clearance rates. Oral IL-17 inhibitors and novel small molecules targeting specific inflammatory pathways are in clinical trials.
Deucravacitinib (Sotyktu) is a first-in-class oral selective TYK2 inhibitor approved by the FDA in September 2022 for moderate-to-severe plaque psoriasis. TYK2 is a Janus kinase that mediates signaling of IL-23, IL-12, and type I interferons — all key pathways in psoriasis. Unlike JAK1/2/3 inhibitors, deucravacitinib selectively inhibits TYK2 through an allosteric mechanism, which provides efficacy without the cardiovascular, thromboembolic, and immunosuppressive risks that led to boxed warnings on other JAK inhibitors. Phase 3 POETYK trials showed that deucravacitinib was superior to placebo and apremilast, with approximately 53 percent achieving PASI 75 at 16 weeks.
Bimekizumab (Bimzelx) represents the cutting edge of IL-17 inhibition by simultaneously blocking both IL-17A and IL-17F, providing more complete suppression of the IL-17 pathway than agents targeting IL-17A alone. In the Phase 3 BE RADIANT head-to-head trial against secukinumab, bimekizumab achieved significantly higher PASI 100 (complete clearance) rates — 61 percent versus 48 percent at week 16. This level of complete clearance was historically unprecedented in psoriasis trials. Oral candidiasis is more common with bimekizumab due to the role of IL-17 in mucosal antifungal defense, occurring in approximately 7 to 16 percent of patients.
Future therapeutic directions include oral IL-17 receptor antagonists that could provide the efficacy of injectable IL-17 inhibitors in pill form, next-generation TYK2 inhibitors with improved dosing, and combination biologic strategies for refractory disease. Research into personalized medicine approaches using biomarkers to predict which patients will respond best to specific therapies is advancing. Additionally, studies on whether aggressive early biologic treatment can modify the long-term disease course of psoriasis — analogous to the treat-to-target approach in rheumatoid arthritis — are underway and could change the treatment paradigm.
Phase 3 BE RADIANT trial showed bimekizumab achieved 61% PASI 100 vs. 48% for secukinumab at week 16
