Dermatologists and Skin Care

General Management of Difficult Psoriasis

Written by Dr. Suvash Sahu and medically reviewed by iCliniq medical review team.



Psoriasis is a chronic genetically influenced immunologically based inflammatory disease of skin and joints. A majority of patients can be managed with topical coal tar, Dithranol and corticosteroids. However, psoriasis has a tendency to recur and may become worse. Moderate to severe psoriasis defined as more than 20% or more body surface area or patient unresponsive to topical therapy are termed as difficult psoriasis.

Types of Difficult Psoriasis

  1. Psoriatic erythroderma means psoriatic lesions involving more than 90% body surface area.
  2. Pustular psoriasis, psoriatic plaques developed with pus filled lesions.
  3. Psoriatic arthritis.
  4. Palmoplantar and scalp psoriasis.
  5. Plaque psoriasis not responding to conventional therapy.

How to Assess Psoriasis Patients

The patient presenting with psoriasis requires a welcoming and sympathetic approach. To understand their condition and aggravating factors, the overall assessment, including patient perception and expectation, life style, other diseases and drugs should be made. Also, previous treatment and their effectiveness and side effects have to be assessed.

Factors Causing Exacerbation of Psoriasis

Stress, alcohol, smoking, trauma, sun, oral corticosteroids, beta blockers, Lithium, drugs used to treat malaria, painkillers, etc.


1) Scalp Psoriasis:

Scalp to be drenched overnight with coconut oil based coal tar and salicylic acid pomade and cover with a shower cap or polyethylene cap. Shampoo the hair only the next morning and use a comb to remove the scales in the scalp. Use potent steroid lotion daily or intermittently. Narrow band UVB (ultraviolet B) is also very effective in scalp psoriasis.

2) Palmoplantar and Pustular Psoriasis:

Topical PUVA (psoralen and ultraviolet A radiation) is the most effective in palmoplantar psoriasis. PUVA usually leads to clearing and may produce long-lasting remissions. For pustular psoriasis, Acitretin is the drug of choice. The usual dose given is 1 mg/kg/day.

3) Psoriatic Arthropathy:

In this type, Methotrexate is the drug of choice. Biologics will also play a role in psoriatic arthritis.

4) Psoriasis in Pregnancy:

Psoriasis in pregnancy is usually managed by topical therapies. Generalized pustular psoriasis of pregnancy is best treated with oral Prednisolone. Cyclosporine is claimed to be compatible with pregnancy, but safety is not established.

5) Psoriasis in Children:

Retinoid appears to be the drug of choice for children, 0.25 to 0.6 mg/kg is the recommended dose. Monitoring with bone scan every 12 to 18 months is recommended for children on retinoid.

Consult a psoriasis specialist online to know more about difficult psoriasis -->

Last reviewed at: 07.Sep.2018



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Related Questions & Answers

Kindly comment on my psoriasis prescription.
Query: Hi doctor, I have been suffering from psoriasis in my palm. When I was 12 years old, I had this disease for the first time. After taking some medicines it disappeared. But, it used to come on and off. In the past one year, I have faced this problem quite often. In between, I had homeopathy. As it ca...  Read Full »
Dr. Atishay Bukharia
Cosmetologist, Dermatologist, Family Physician, General Practitioner, HIV AIDS Specialist, Plastic Surgeon, Venereologist

Answer: Hi, Welcome to Yes, your treatment is right. But, do not take Folitrax for long duration (Methotrexate) as it can adversely affect your liver and immunity. Also, if it is limited to palm and soles, then there is no need to take it. Because, Folitrax is meant for use in severe pso...  Read Full »

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