Rethinking Psoriasis Severity: What DermPAs Should Know About International Psoriasis Council Guidance and Topical Treatment Failure

Sep 25, 2026

By Kelly Swanson*, PA-C

Sponsored by Johnson & Johnson 

We all know patients with plaque psoriasis who can be tough to classify. A patient may have plaque psoriasis covering only a small percentage of their body, but it can affect their palms, so every handshake, keyboard stroke, or daily task can become painful. For some patients, persistent plaque psoriasis on their scalp can be difficult to hide and increasingly affects confidence at work or in social settings. Others may have spent months moving through topical treatments without meaningful improvement, as plaque psoriasis continues to interfere with their daily life.

These patients may not always meet traditional definitions of moderate-to-severe plaque psoriasis based on body surface area (BSA) alone. But their disease burden can still be significant, and it is time to look at treatment needs differently.

For DermPAs caring for patients with plaque psoriasis, 2025 updated guidance from the International Psoriasis Council (IPC) provides a broader way to think about disease severity and when to consider a treatment reassessment.

Looking Beyond Body Surface Area

Historically, psoriasis severity has been categorized based on measures such as body surface area and the Psoriasis Area and Severity Index (PASI). While these measures remain useful, they may not fully capture the impact of plaque psoriasis on a patient’s daily life.

The IPC’s 2025 updated disease severity framework takes a broader approach. Patients may be considered candidates for systemic therapy when they meet any one of 3 criteria:

• BSA involvement greater than 10%
• Psoriasis involving high-impact sites, such as the face, scalp, palms, soles of the feet, or groin
• Failure of topical therapy

That means a patient does not necessarily need widespread plaque psoriasis to experience disease that warrants a different treatment approach. For DermPAs, learning more about where plaque psoriasis occurs on a patient’s body and how it is affecting their ability to work, sleep, socialize, or complete daily activities can provide important context beyond BSA alone.

When Is It Time to Move Beyond Topicals?

Topical therapies remain an important part of plaque psoriasis management, but when they are not enough to adequately control disease, patients may spend additional weeks, months, or – in some cases – years living with uncontrolled disease. We’ve learned more about the impact of inadequately controlled plaque psoriasis, which can extend beyond persistent skin symptoms. Plaque psoriasis can be associated with conditions including psoriatic arthritis and cardiovascular and metabolic disease, making ongoing assessment of disease burden and related comorbidities an important part of long-term care.

2025 updated IPC guidance provides greater clarity about what constitutes topical treatment failure. In general, failure may be considered when an appropriate topical regimen, typically two treatment cycles of approximately four weeks each, does not result in meaningful improvement. Topical therapy may also be considered unsuccessful when use is limited by factors such as sensitivity in high-impact areas, adherence challenges, or persistent quality-of-life impairment.

In practice, that means asking more than, “Is the patient still using the topical?”

It may also mean asking:

• Has there been improvement in the extent, severity, symptoms, or visibility of the plaque psoriasis, or are lesions still present or worsening?
• Is the treatment practical for the location and extent of disease?
• Is the patient able and willing to use it consistently?
• Is plaque psoriasis still affecting daily activities, work, sleep, exercise, relationships, or comfort—even if the patient has developed ways to work around it?

Patients may not always describe the impact of their disease as “interference” with daily living. They may avoid certain clothing, hairstyles, activities, social situations, or physical contact; adjust how they work or sleep; or plan their routines around applying treatment and managing symptoms and therefore consider themselves to be coping. Asking what the patient has stopped doing, changed, or learned to work around can help reveal the extent of the impact of plaque psoriasis. These details may indicate that the current treatment approach is not adequately meeting the patient’s needs and that a treatment change or broader reassessment may be appropriate. 

If the answers to these deeper questions point to inadequate control, it may be time to reassess the treatment plan rather than simply continuing another cycle of topical therapy.

What Can DermPAs Do? 

As we observe APP week, I want to commend my fellow DermPAs for the expertise, advocacy and persistence you bring to patient care every day. We all play a critical role in recognizing the full burden of plaque psoriasis, asking the right questions, and helping patients get the care they need. 

For DermPAs, the IPC guidance offers a practical reminder: look beyond the percentage of skin involved.

Consider high-impact locations. Ask about quality of life and functional burden. Review how the patient has responded to topical treatment—and whether continuing with the same approach is likely to meet their needs. 

Recognizing topical treatment failure earlier may help identify patients who warrant reevaluation of their treatment strategy. Including consideration of systemic therapy when appropriate.

A relatively small area of psoriasis can have an outsized impact on a patient's life. A broader assessment of severity can help ensure the treatment approach reflects that reality. 

For Patients Who May Be Candidates for Systemic Therapy

Learn more about a treatment option that may be appropriate for patients with moderate-to-severe plaque psoriasis: https://ow.ly/XNk150ZQY3m

 

*Kelly Swanson has been compensated by Johnson & Johnson for her time to develop this content.

References

1. Strober BE, Blauvelt A, van de Kerkhof PC, et al. International Psoriasis Council psoriasis disease severity reclassification: Update on validity, acceptance, and implementation. J Am Acad Dermatol. 2025;93(4):1154-1157. doi:10.1016/j.jaad.2025.05.1445
2. Strober BE, Blauvelt A, van de Kerkhof PCM, et al. Establishing consensus on defining failure of topical therapy in psoriasis: Recommendations from the International Psoriasis Council. J Am Acad Dermatol. Published online September 11, 2025. doi:10.1016/j.jaad.2025.08.116

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