Although there is no cure for psoriasis, there are a variety of effective treatment options that can clear the skin lesions caused by psoriasis.
Treatment Plan Factors
Your doctor will recommend one or more psoriasis treatments depending on the following factors:
1) Type of psoriasis
Treatments are more effective at treating some types of psoriasis than others. For instance, lasers are effective at treating an isolated lesion of plaque psoriasis, but they are not practical for treating the widespread lesions of guttate psoriasis. Similarly, the use of a PUVA lightbox (phototherapy) is usually impractical for the treatment of a single psoriasis lesion.
Some types of psoriasis, such as pustular psoriasis, are associated with greater inflammation and greater risks, so are treated more aggressively than other types.
2) Location of psoriasis lesions (trunk vs. hands/feet, vs. scalp)
The location of the psoriasis lesions can determine the optimal treatment. For instance, scalp psoriasis might benefit from the application of a shampoo containing a corticosteroid (i.e. clobetasol). However, lesions that appear in the groin or underarms may require the use of a different medication due to the sensitivity of the skin there.
3) Psoriasis severity (mild, moderate or severe).
The severity of a psoriasis flare, as determined by the amount of skin affected (BSA), can determine how aggressively to treat a particular psoriasis flare. For instance, severe psoriasis affecting more than 10% of the body may justify treatment with a biologic or oral medication, whereas a mild psoriasis flare affecting less than 1% of the body might be treated effectively with topical medications, such as an ointment.
4) Possible side effects and convenience of a treatment
Psoriasis medications are prescribed in a step-wise fashion. The first medication(s) prescribed are selected to be effective, convenient and least likely to lead to side effects. If the first medication(s) fails to bring psoriasis under control, a “stronger” medication may be then be prescribed, but these may be associated with additional risks. For instance, a mild or moderate strength corticosteroid may be prescribed prior to using a superpotent corticosteroid.
Some psoriasis treatments are associated with greater risks the longer or more frequently they are used. For instance, cyclosporine and methotrexate can only be used for a limited amount of time prior to switching to alternative treatments. Similarly, the use of PUVA may be limited due to the long-term damage to the skin from excessive use.
5) Results of previous psoriasis treatments
Since psoriasis treatments may work better for some patients than others, be prepared to try more than one treatment.
If a particular treatment regimen is found to be safe and effective for an individual, that treatment may be recommended again for a similar flare.
Topical Psoriasis Medications: Over-the-counter
For mild to moderate psoriasis, many people may find sufficient relief from one or more of the following creams or ointments applied to the skin.
- Moisturizers—While moisturizers won’t actually heal psoriasis lesions, they can reduce the itching and scaling. For psoriasis, the greasier moisturizers provide more relief, so choose ointments over lighter creams and lotions.
- Coal tar—One of the oldest known treatments for psoriasis, coal tar is available without a prescription as a shampoo, gel, and cream. Coal tar reduces inflammation, slows the growth of skin cells, and relieves itching and irritation. It can be messy to apply and has a strong odor.
- Salicylic acid—This medication is available in shampoos, creams, lotions, pads, paste, and soap. It works as a peeling agent, removing scales from the skin, and it’s often combined with other topical treatments.
Topical Medications: Prescription-Only
- Anthralin (Micanol®) – An established, safe treatment for psoriasis (especially of the scalp), anthralin slows down skin cell growth and reduces inflammation. The medication may stain clothing and nearby unaffected skin.
- Calcipotriene (Dovonex®, Taclonex®, Sorilux®) – This synthetic form of vitamin D slows skin cell growth, flattens psoriasis lesions, and removes scales. It doesn’t control inflammation, but most patients notice a reduction of skin redness.
- Calcitriol (Vectical®) – Vectical® contains calcitriol, the naturally occurring and active form of vitamin D3. This topical psoriasis treatment slows down the over-production of skin cells that occurs with psoriasis, and it is thought to help decrease the excessive immune response on the skin of patients with psoriatic lesions. Vectial is well tolerated, and may be used on skin folds.
- Corticosteroids (“topical steroids”) – Corticosteroids slow skin cell growth and relieve itching by suppressing the immune system. They work quickly and are easy to use. Corticosteroid may be used alone for mild psoriasis or combined with other therapies for severe lesions. Side effects include thinning of the skin, stretch marks, and reduced immune function, so prolonged use of corticosteroids should be avoided.
- Topical retinoids (Tazorac®) – Retinoids are a class of medications derived from vitamin A that are used for a variety of skin conditions, including acne and psoriasis. Some retinoids have been formulated for use on the skin. Tazorac® is a topical retinoid that has been approved by the FDA for the treatment of psoriasis.
- Calcineurin inhibitors (Elidel®, Protopic®) – Calcineurin inhibitors, also called topical immunomodulators, are medications that are typically prescribed for atopic dermatitis (eczema), but may be used in some cases of psoriasis.
Oral medications may be prescribed for people with moderate to severe psoriasis whose psoriasis lesions do not respond sufficiently to topical medications or phototherapy. Because these medications are taken by mouth and absorbed into the blood, they reach the deeper layers of skin throughout the body.
These psoriasis medications can be very effective, but also have serious potential side effects to consider. Oral psoriasis treatments include:
- Cyclosporine for psoriasis (Neoral®)—By suppressing the immune system, cyclosporine slows the overgrowth of skin cells and is particularly effective against plaque and nail psoriasis. Cyclosporine is a fast-acting medication that is often used first-line for pustular psoriasis or erythrodermic psoriasis. It may also be used intermittently for periods of several months to provide rapid relief of a flare of psoriasis. Because of cyclosporine’s significant side effects, people taking this medication are monitored closely.
- Methotrexate for psoriasis—Like cyclosporine, methotrexate suppresses the immune system and is sometimes prescribed for the treatment of erythrodermic and pustular psoriasis, as well as psoriatic arthritis. Methotrexate may be used as a first-line treatment for plaque psoriasis, but it tends to have a more modest affect compared to cyclosporine. However, methotrexate can be used continuously for years or decades. Because of methotrexate’s significant side effects, people taking this medication are monitored closely.
- Soriatane (Acitretin®)—“Retinoids” refers to a class of medications derived from vitamin A that are used for a variety of skin conditions. Soriatane® is retinoid that is FDA approved specifically for the treatment of multiple types of psoriasis. It is considered a first-line treatment for chronic palmoplantar or pustular psoriasis in patients of nonchildbearing potential, but is of limited benefit for plaque psoriasis. It is often combined with other treatments, including calcipotriene (Taclonex®) and phototherapy.
Other oral treatments for psoriasis that might be considered include isotretinoin (Accutane®, Sotret®), hydroxyurea, mycophenolate (Cellcept®), and sulfasalazine.
Phototherapy for Psoriasis
As the name implies, phototherapy involves the use of light to treat psoriasis.
Phototherapy may use UVA or UVB rays. Although excessive exposure to UV radiation increases a person’s risk of developing skin cancer, it has been shown that UV light can suppress T cell activity within the immune system and slow down the uncontrolled growth of skin cell. This leads to a reduction in the scaly plaques of psoriasis.
Before trying a sunlight or phototherapy regimen, seek the guidance of your doctor to make sure you don’t overexpose your skin to UV radiation and aggravate your symptoms.
There are three main types of phototherapy:
- UVB—During this therapy, the skin is exposed to controlled amounts of UVB light. The UVB light may be administered in a doctor’s office or delivered via a home unit obtained by prescription.
- PUVA (“psoralen UVA”) – PUVA treatment combines UVA light exposure with a light-sensitizing medication called a “psoralen” (PUVA = psoralen + UVA ). PUVA can provide long-term symptom relief by slowing skin cell growth.
- Lasers for psoriasis – Select types of lasers can deliver intense beams of UV light directly to the affected skin to treat scaling and inflammation, leaving surrounding skin intact. Because it is so targeted, lasers can often provide satisfactory results after a few sessions.
Combination Therapy for Psoriasis
Some cases of psoriasis require the combination of different treatments to achieved desired results. For instance, Tazorac® may be combined with a topical corticosteroid, or Soriatane® may be combined with phototherapy. Your doctor may recommend different combinations at different times.
Rotating Therapies for Psoriasis
Long-term use of some medications, such a cyclosporine or methotrexate, can lead to an increased risk of side effects. In addition, the benefits of some medications can diminish over time. In such cases, doctors may recommend rotating medications, using one medication for several months followed by a different medication. For example, coal tar may be rotated with cyclosporine.
Biologics for the Treatment of Psoriasis
Biologics (also called “disease-modifying therapy” or “immunomodulators”) are a relatively new treatment option for people with moderate to severe psoriasis. They are given this name because they are derived from human or animal proteins instead of chemicals like most other medications.
Biologics work by targeting specific parts of the immune system, such as T cells or TNF (tumor necrosis factor), a chemical used to transmit messages between immune cells. This focused approach reduces the likelihood of side effects seen with medications that affect the entire immune system.
Biologics must be administered by injection, either into the skin (subcutaneously), into the muscle (intramuscular or IM), or by intravenous infusion (IV). Subcutaneous injections are similar to the insulin shots used by someone with diabetes and can be administered by the person with psoriasis or a caregiver.
There are currently four biologic medications that are FDA approved for the treatment of psoriasis.
- Etanercept (Enbrel®)
- Adalimumab (Humira®)
- Infliximab (Remicade®)
- Ustekinumab (Stelara®)
Some biologics may require long-term use to keep psoriasis under control. Stopping treatment can lead to a premature return of symptoms.
Image courtesy of Wikipedia. Photo shows results of therapy with infliximab.