Maintenance therapy in moderate to severe chronic plaque psoriasis: Role of weekend cyclosporin treatment

Disease relapse in psoriasis is common, often with lesions recurring at previously treated sites. This is due to residual pathogenic tissue memory T cells that are capable of initiating relapse by producing inflammatory cytokines such as interleukin (IL)-17 and IL-23. Current psoriasis treatment is mostly reactive, addressing relapses as they occur, which leads to short-term clearance but not lasting remission.¹

A long-term management approach is now recommended by experts with the aim to sustain treatment response, reduce flares, minimise drug exposure (and consequently the cumulative dose), ensure long-term safety, avoid tachyphylaxis, and improve cost optimisation and treatment adherence, thus resulting in better patient outcomes.

The concept of topical maintenance therapy is not new to dermatologists. It has been used in several disorders like atopic dermatitis, seborrheic dermatitis, vulvar lichen sclerosus, and even in condyloma acuminata.² Particularly in psoriasis, we have decades of experience with various approaches to maintenance therapy like the continuous long-term therapy, chronic intermittent use, step-down therapy, sequential regimens, and topical proactive maintenance therapy.³

Emerging evidence supports the role of systemic proactive or weekend treatment after skin clearance. It can be implemented by determining the minimum effective dose required to maintain disease control, which can be achieved in two ways – either by reducing the dose (acitretin, methotrexate, ciclosporin) or by spacing intakes (adalimumab, ustekinumab). This may be especially useful in patients with significant quality of life impairment, seasonal triggers, or those who experience quick relapse after stopping treatment.⁴

In this context, the article titled ‘Efficacy and safety of weekend cyclosporine treatment (WCT) as maintenance therapy for preventing frequent disease exacerbations in moderate to severe chronic plaque psoriasis patients – a retrospective cohort study’ offers a promising alternative to continuous cyclosporine therapy.⁵ Cyclosporine, a widely used therapy for rapid remission, often poses long-term toxicity risks. The study demonstrates that WCT (Saturday-Sunday dosing) can effectively maintain disease control in a significant number of patients who initially responded to continuous therapy. The ability to reduce drug exposure while maintaining efficacy is a major advantage, especially in chronic conditions requiring lifelong treatment. Additionally, the study shows fewer adverse events compared to continuous therapy, making WCT an attractive option. While topical weekend therapy with corticosteroids is common in atopic dermatitis and psoriasis, WCT has not been extensively studied, which highlights the novelty of this approach.

From a clinical perspective, this regimen offers several practical advantages. It simplifies the treatment schedule and reduces the psychological and economic burden of daily medication, which may improve long-term treatment adherence. However, the study is not without limitations. While the retrospective design is pragmatic, it cannot establish causality or account for all potential confounders. Additionally, the study population may not be representative of all psoriasis patients, limiting the generalisability of the results.

While the study provides a strong foundation, further research, particularly prospective randomised controlled trials, is needed to validate these findings and assess long-term outcomes, including safety. As newer biologics and small molecule inhibitors emerge, the role of cyclosporine – especially in a weekend-only format – needs reassessment within the broader therapeutic landscape. If validated through future studies, this regimen could represent a significant advance in long-term psoriasis management, offering patients a more tolerable and sustainable option.

Several key questions remain, nevertheless: How and when should patients transition from continuous to long-term therapy? What are the safety and efficacy implications of various maintenance strategies? How should maintenance therapy be monitored? Is there a rebound effect after discontinuation? And is there a specific patient profile or lesion type more suited to maintenance therapy? Identifying the right patient profile and addressing these questions will guide future clinical decisions and refine the role of WCT in psoriasis management.