PSORIASIS TREATMENT failure is a crucial concept in modern dermatology, as timely and effective therapy not only improves quality of life but may also prevent serious comorbidities such as psoriatic arthritis and cardiovascular disease. Achieving clear or nearly clear skin is now an accepted treatment goal, yet patients who should be considered for systemic therapy are often started on topical agents, delaying effective care.
The International Psoriasis Council (IPC) has outlined clear criteria to help clinicians determine when systemic therapy should be prioritised. According to these guidelines, patients meet the threshold for systemic treatment if they have a body surface area (BSA) involvement greater than 10%, psoriasis affecting high-impact sites such as the face, scalp, or genitals, or if they fail to respond to topical therapy.
Escalating Psoriasis Treatment Beyond Topicals
The IPC Disease Severity Working Group defines psoriasis treatment failure as the inability to achieve clear or nearly clear skin, BSA ≤1% and a Physician’s Global Assessment of 0 or 1, after two consecutive 4-week courses of topical treatment. Importantly, patient-reported outcomes are emphasised: if individuals describe their psoriasis as moderate or severe, despite a clinician’s milder assessment, and experience significant social, psychological, or physical burden, escalation to systemic therapy should be considered.
While topical treatments may remain useful for extended periods, potent corticosteroids must be used cautiously: no more than 4 weeks for potent preparations and 2–4 weeks for super-potent ones. If adequate response is not achieved in this timeframe, transitioning to ultraviolet phototherapy or systemic therapy is recommended. Topical treatments can still serve as adjuvants for stubborn lesions.
Reducing the Long-term Burden of Psoriasis
By recognising psoriasis treatment failure early and initiating appropriate systemic or phototherapy options, clinicians can help patients achieve predictable skin clearance. This reduces frustration, enhances adherence, and mitigates the cumulative lifelong burden of psoriasis. Regional guidelines and individual patient factors, including age, comorbidities, and treatment accessibility, should guide final decisions. Ultimately, aligning management with IPC guidance ensures patients have the best chance of reaching meaningful treatment outcomes.
Reference
Strober BE et al. Establishing consensus on defining failure of topical therapy in psoriasis: recommendations from the International Psoriasis Council. J Am Acad Dermatol. 2025;DOI:10.1016/j.jaad.2025.08.116.
