Table 4.

Advantages and limitations of psoriasis therapy

Therapies		Advantages	Limitation
Traditional therapy
Topical corticosteroids		Used for mild or localized psoriasis; Used for the acute phase of active psoriasis;	Long-term daily use of high-potency corticosteroids over large body surface areas is avoided in children. Rebound can occur from abrupt withdrawal. Common adverse reactions of topical corticosteroids include skin folliculitis, striae, telangiectasia, and atrophy.
Topical Vitamin D Analogues		Used liberally as long as the patient does not have renal impairment.	Modest efficacy when used lonely. Common adverse reactions include edema, burning, dryness, pruritus, erythema, and peeling. The rare adverse reaction includes hypercalcemia and parathyroid hormone suppression when exceeding the recommended dose.
Combination of topical corticosteroids and calcipotriol		Higher efficacy, fewer adverse effects, and longer remission than a monotherapy	Skin irritation occurs infrequently.
Topical calcineurin inhibitors		The important treatment methods for localized psoriasis. Used on thinner skin, such as facial and intertriginous areas; Used as steroid-sparing agents for prolonged use;	Common adverse reactions include burning and pruritus.
Topical keratolytic agents		One of the important treatment methods for localized psoriasis. Topical preparations with few systemic adverse reactions.	Common adverse reactions include erythema, burning, and pruritus. Tazarotene is avoided in pregnancy; Salicylic acid should exercise caution in children and patients with renal disease or hepatic disease; Salicylic acid should not be applied before phototherapy.
Coal tar		–	Rarely used due to its mutagenicity.
Methotrexate		The most commonly used treatment option before introducing biologics for moderate-to-severe psoriasis.	Adverse reactions include hepatotoxicity and severe gastrointestinal reactions, pneumonitis, pulmonary, fibrosis, bone marrow suppression, and teratogenicity. Contraindicated in case of renal insufficiency.
Cyclosporine		One of the important treatment methods for moderate-to-severe psoriasis. More effective than methotrexate in treating plaque psoriasis.	Adverse reactions include more severe renal toxicity, hypertension, hypomagnesemia, hyperkalemia, hyperlipidemia, lymphoma, and skin cancer risks; Not suitable for long-term use due to irreversible nephrotoxicity.
Acitretin		Efficacy in various types of psoriasis, particularly in erythrodermic psoriasis and pustular psoriasis.	Contraindicated in women of childbearing age due to teratogenicity, others include dry skin, dyslipidemia, and elevation of transaminases.
Psoralen and UV-A (PUVA)		Higher lesion clearance and longer maintenance in plaque psoriasis compared to NB-UVB.	The development of skin cancer with long-term use. Common adverse reactions include burning, gastro, photoaging, intestinal upset, and pruritus.
Narrow-band ultraviolet B (NB-UVB)		Efficacy in plaque psoriasis. Safer than PUVA.	Common adverse reactions include pruritus, erythema, blistering, photoaging.
Targeted therapy
Target	Molecule	Advantages	Limitation
TNF-α	Etanercept Infliximab Adalimumab	Significant efficacy in various types of psoriasis than traditional treatments. TNF inhibitors are preferred in targeted therapy for psoriatic arthritis. Patients with a history of concomitant inflammatory bowel disease (IBD) might benefit from TNF-a inhibitors (Infliximab; Adalimumab).	Common adverse reactions include upper respiratory tract infection, nasopharyngitis, headache, and infusion-related reactions. Specific adverse reactions include paradoxical reactions, multiple sclerosis (rare), exacerbation or new onset of CHF, and Hepatotoxicity (especially with infliximab). Avoid use in patients with demyelinating disease, hepatitis B, latent tuberculosis, serious infection, and advanced congestive heart failure.
IL-17	Secukinumab Ixekizumab Brodalumab Bimekizumab	Significant efficacy in plaque psoriasis, psoriatic arthritis, and nail psoriasis. Adverse reactions and paradoxical reactions occur less frequently than TNF-α inhibitors.	Common adverse reactions include infection, headache, neutropenia, and injection site reaction. Specific adverse reactions include an increased risk of mucocutaneous Candida infection and inflammatory bowel disease (IBD), increased liver transaminases (Secukinumab), suicidal ideation, and completed suicides (Brodalumab). Avoid use in patients with IBD, history of allergic reaction to the therapeutic agents or vehicle, and serious infection.
IL12/IL23p40	Ustekinumab	Significant efficacy in plaque psoriasis, psoriatic arthritis, and nail psoriasis. When paradoxical reactions occur in psoriasis treated with TNF-α inhibitors, switching to Ustekinumab may be considered to treat psoriasis and the symptoms of paradoxical reactions that occur.	Common adverse reactions include upper respiratory tract infection, nasopharyngitis, neutropenia, and headache. Specific adverse reactions include hypersensitivity reactions (anaphylaxis and angioedema). Avoid use in patients with a history of allergic reactions to the therapeutic agents or vehicle and serious infections. Less effective than TNF-a inhibitors for psoriatic arthritis.
IL-23p19	Guselkumab Tildrakizumab Risankizumab	Significant efficacy in plaque psoriasis, psoriatic arthritis, and nail psoriasis.	Common adverse reactions include nasopharyngitis, upper respiratory tract infection, headache, arthralgia, and back pain. Specific adverse reactions include increased liver transaminase levels (rare). Avoid use in patients with febrile illness and a history of allergic reactions to the therapeutic agents or vehicle.
IL-36/IL-1	Spesolimab Imsidolimab	Significant efficacy in generalized pustular psoriasis (GPP). Convenient mode of administration: oral.	Adverse reactions include drug-induced liver injury, urinary tract infection, arthritis, drug reaction with eosinophilia, and systemic symptoms. Its’ efficacy and safety are still under investigation.
JAK	Tofacitinib Upadacitinib Deucravacitinib	Significant efficacy in psoriatic arthritis (tofacitinib and upadacitinib). Significant efficacy in plaque psoriasis (deucravacitinib). Convenient mode of administration: oral.	Adverse effects include infection, hemoglobin reduction, thrombocytopenia, gastrointestinal perforation, and nausea. Rare adverse reactions include lymphoma (deucravacitinib). Most selective JAK inhibitors are still under investigation and yet to be approved for marketing.
PDE4	Apremilast Roflumilast	Significant efficacy in psoriatic arthritis (Apremilast) and plaque psoriasis (Apremilast and Roflumilast). A topical cream with low rates of adverse effects (Roflumilast)	The application of Apremilast is hampered by its side effect, emesis. The roflumilast cream efficacy compared with other active treatments and longer-term efficacy and safety need to be further assessed.
RORγt	VTP-43742	Potential candidates for the treatment of psoriasis.	Absence of adequate clinical study data to demonstrate efficacy and identify adverse reactions.
IL-22	ILV-095	A new target for the treatment of psoriasis.	Primary efficacy endpoints could not be met.
IFN-α	MEDI-545	–	Its’ efficacy still remains unclear.
Other clinical research progress
–	Mesenchymal stem cells (MSCs)	Improvement of the symptoms of patients with psoriasis.	The absence of adequate clinical study data on the approach has been conducted, and the type, mode, dose, and frequency of MSCs infusion are still under exploration.
AhR	Tapinarof	Topical preparations with few systemic adverse reactions.	Low rate of adverse reactions, such as burning, stinging, and itching. Absence of adequate clinical study data to demonstrate efficacy and identify adverse reactions.
S1PR1	Ponesimod	A new target for the treatment of psoriasis. Convenient mode of administration: oral	Adverse reactions include dyspnea, elevation of liver enzymes, and dizziness. Absence of adequate clinical study data to demonstrate efficacy and identify adverse reactions.