›Screen for TB and hepatitis B before initiation
›Spesolimab (anti-IL-36 receptor monoclonal antibody)
›FDA-approved for GPP flares in adults
›Dose: 900 mg IV single dose for acute GPP flare
›Rapid pustule clearance within days
Topical therapy: mild flare (<5% BSA)
›First-line topical agents
›High-potency topical corticosteroids
›Clobetasol propionate 0.05% cream or ointment BID for trunk and extremities
›Betamethasone dipropionate 0.05% as alternative
›Limit to 4 weeks on body to avoid skin atrophy and rebound
›Taper over 2 weeks once lesions clear (every other day x 1 week, then twice weekly)
›Low-potency corticosteroids for face and intertriginous areas
›Hydrocortisone 1-2.5% BID for sensitive areas
›Vitamin D analogues (calcipotriene)
›Calcipotriene 0.005% cream or ointment once or twice daily
›Combination with topical corticosteroid is superior to monotherapy
›Calcipotriene/betamethasone dipropionate aerosol foam: once daily for 4 weeks
›Avoid on face and skin folds (irritation)
›Calcineurin inhibitors
›Tacrolimus 0.1% ointment twice daily for face and flexural areas
›Pimecrolimus 1% cream as alternative for sensitive sites
›Preferred over corticosteroids for face and intertriginous areas (no atrophy risk)
›Keratolytics
›Salicylic acid 2-6% for thick plaques before applying other topicals
›Enhances penetration of subsequent topical agents
›Scalp psoriasis treatment
›Calcipotriene/betamethasone dipropionate gel or foam for 4-12 weeks
›Apply to scalp at night, shampoo off in morning
›Coal tar shampoo: adjunct for scale removal
›Clobetasol 0.05% solution or foam for scalp
Systemic therapy: moderate-to-severe flare (>5% BSA)
›Phototherapy
›Narrowband UVB (NBUVB)
›2-3 sessions per week in clinic or home unit
›Preferred over PUVA for safety profile
›Effective for plaque and guttate psoriasis
›Pregnancy-safe option for widespread disease
›Systemic nonbiologic agents
›Methotrexate
›Starting dose: 7.5-15 mg orally or subcutaneously once weekly
›Titrate to 15-25 mg/week based on response and tolerability
›Folic acid 1-5 mg daily (given 6 days per week) to reduce side effects
›Assess PASI at 4 weeks; switch if <25% improvement
›Monitor CBC and LFTs every 4-8 weeks during dose escalation
›Contraindicated in pregnancy, active hepatitis, significant renal impairment
›Cyclosporine
›Dose: 2.5-5 mg/kg/day in two divided doses
›Rapid onset: useful for acute flares requiring quick control
›Limit to 1-2 years of continuous use
›Monitor blood pressure and creatinine every 2-4 weeks
›Target creatinine increase <30% above baseline
›Acitretin
›Dose: 25-50 mg/day with main meal
›Slower onset but effective for pustular and erythrodermic variants
›Combination with NBUVB increases efficacy (re-PUVA approach)
›Monitor lipids (causes triglyceride elevation) and liver function
›Apremilast (PDE4 inhibitor)
›Titration: start 10 mg AM day 1, titrate to 30 mg BID by day 6
›No laboratory monitoring required (advantage over other systemics)
›Common side effect: diarrhea and nausea (usually resolves by week 6)
›Moderate efficacy; alternative when biologics not available or contraindicated
›Biologic therapy (first-line per AAD-NPF for moderate-to-severe disease)
›IL-23 inhibitors (highest efficacy class)
›Risankizumab 150 mg SC at weeks 0, 4, then every 12 weeks
›PASI 90 rates approximately 75% at week 16
›Guselkumab 100 mg SC at weeks 0, 4, then every 8 weeks
›PASI 90 rates approximately 70% at week 16
›Tildrakizumab 100-200 mg SC at weeks 0, 4, then every 12 weeks
›IL-17 inhibitors (very high efficacy, rapid onset)
›Secukinumab 300 mg SC weekly for 5 weeks, then monthly
›PASI 90 rates approximately 60-70% at week 16
›Ixekizumab 160 mg SC at week 0, then 80 mg every 2 weeks for 12 weeks, then monthly
›Bimekizumab 320 mg SC every 4 weeks for 16 weeks, then every 8 weeks
›Dual IL-17A and IL-17F inhibition; highest reported PASI 90/100 rates
›TNF-alpha inhibitors
›Infliximab 5 mg/kg IV at weeks 0, 2, 6, then every 8 weeks
›Fastest biologic onset; preferred for rapid control in severe flare
›Adalimumab 80 mg SC week 0, 40 mg week 1, then 40 mg every 2 weeks
›Etanercept 50 mg SC twice weekly for 12 weeks, then once weekly
›IL-12/23 inhibitor
›Ustekinumab 45 mg SC (or 90 mg if >100 kg) at weeks 0, 4, then every 12 weeks
›Contraindicated or high-risk medications in psoriasis
›Systemic corticosteroids
›Avoid initiating or rapidly tapering systemic corticosteroids
›Risk of rebound flare, progression to erythroderma, or GPP induction
›Avoid or use caution: lithium, beta-blockers, antimalarials, NSAIDs
›Discuss risk-benefit with prescribing clinician if these drugs are necessary
›Biologic therapy contraindications
›Active infection or sepsis: hold biologic until infection resolved
›Active TB: treat latent TB for 1-2 months before anti-TNF initiation
›Demyelinating disease: avoid TNF inhibitors
›Active hepatitis B: requires antiviral prophylaxis before biologic use