Therapeutic strategies: rotational therapy and combinations

Long-term management of psoriasis requires an individualized approach. Some treatments such as calcipotriol, methotrexate and acitretin may be used as maintenance treatment for many months. However, most anti-psoriasis treatments should be prescribed for restricted periods of time. Rotational treatment is a practical approach to reduce the cumulative toxicity of anti-psoriasis treatments. The selection of a treatment is based on the clinical presentation of psoriasis and whether contraindications might exist. Combination treatment is another approach, which is used by the majority of patients. Useful combinations are calcipotriol-acitretin, calcipotriol-cyclosporin, calcipotriol-PUVA, calcipotriol-topical corticosteroids, dithranol-UVB, dithranol-tar, coaltar-UVB, acitretin-UVB and acitretin-PUVA. Combinations which are contraindicated are coaltar-PUVA, UVB-cyclosporin, PUVA-cyclosporin and methotrexate-acitretin. Combined use of UVB-methotrexate, UVB-PUVA; PUVA-methotrexate; methotrexate-cyclosporin and cyclosporin-acitretin require careful monitoring and might be helpful in patients with severe and recalcitrant psoriasis. Depending on the individual presentation of psoriasis, previous anti-psoriatic treatments and side-effects, treatment adjustments are made.