There are many effective treatment choices for psoriasis. The best treatment is individually determined by the treating physician and depends, in part, on the type of disease, the severity, and the total body area involved.
For mild disease that involves only small areas of the body (like less than 10% of the total skin surface), topical (skin applied) creams, lotions, and sprays may be very effective and safe to use. Occasionally, a small local injection of steroids directly into a tough or resistant isolated psoriatic plaque may be helpful.
For moderate to severe disease that involves much larger areas of the body (like 20% or more of the total skin surface), topical products may not be effective or practical to apply. This may require ultraviolet light treatments or systemic (total body treatments such as pills or injections) medications. Internal medications usually have greater risks. Because topical therapy has no effect on psoriatic arthritis, systemic medications are generally required to stop the progression to permanent joint destruction.
It is important to keep in mind that as with any medical condition, all medications carry possible side effects. No medication is 100% effective for everyone, and no medication is 100% safe. The decision to use any medication requires thorough consideration and discussion with your physician. The risks and potential benefit of medications have to be considered for each type of psoriasis and the individual patient. Of two patients with precisely the same amount of disease, one may tolerate it with very little treatment, while the other may be almost completely become incapacitated and require treatment internally.
A proposal to minimize the toxicity of some of these medicines has been commonly called "rotational" therapy. The idea is to change the anti-psoriasis drugs every six to 24 months in order to minimize the toxicity of one medication. Depending on the medications selected, this proposal can be an optimal option. An exception to this proposal is the use of the newer biologics medications as described below. A patient who has been using strong topical steroids over large areas of their body for prolonged periods may benefit from stopping the steroids for a while and rotating onto a different therapy, like calcitriol (Vectical), light therapy, or an injectable biologic.
What creams, lotions, and home remedies are available for psoriasis?
Topical (skin applied) medications include topical corticosteroids, vitamin D analogue creams like calcitriol, topical retinoids (tazarotene [Tazorac]), moisturizers, topical immunomodulators (tacrolimus and pimecrolimus), coal tar, anthralin, and others.
- Topical corticosteroids (steroids, such as hydrocortisone) are very useful and often the first-line treatment for limited or small areas of psoriasis. These come in many preparations, including sprays, liquid, creams, gels, ointments, and foams. Steroids come in many different strengths, including stronger ones that are used for elbows, knees, and tougher skin areas and milder ones for areas like the face, underarms, and groin. These are usually applied once or twice a day to affected skin areas. Strong steroid preparations should be limited in use. Overuse or prolonged use may cause problems, including potential permanent skin thinning and damage called atrophy.
- Calcitriol cream is useful in psoriasis because of its effect on calcium metabolism. The advantage of calcitriol is that it is not known to thin the skin like topical steroids. A similar drug, calcipotriene, may be used in combination with topical steroids for better results. There is a newer combination preparation of calcipotriene and a topical steroid called Taclonex. Not all patients may respond to calcipotriene. Prolonged use of these types of medications on more than 20% of the skin surface can produce a abnormal rise in body calcium levels.
- Moisturizers, especially with therapeutic concentrations of salicylic acid, lactic acid, urea, and glycolic acid may be helpful in psoriasis. These moisturizers are available as prescription and nonprescription forms. These help reduce the scales that impede the movement of topical medications into the deeper layers of the skin. Some available preparations include salicylic acid (Salex), lactic acid (AmLactin, Lac-Hydrin). These may be used one to three times a day on the body. Other bland moisturizers, including Vaseline and Crisco vegetable shortening, may also be helpful in at least reducing the dry appearance of psoriasis.
- Immunomodulators (tacrolimus and pimecrolimus) have also been used with some limited success in mild psoriasis. These have the advantage of not causing skin thinning. They may have other potential side effects, including skin infections and possible malignancies (cancers). The exact association of these immunomodulator creams and cancer is controversial.
- Bath salts or bathing in high-salt-concentration waters like the Dead Sea in the Middle East along with careful exposure to sunlight can be beneficial to psoriasis patients.
- Coal tar is available in multiple preparations, including shampoos, bath solutions, and creams. Coal tar may help reduce the appearance and decrease the flakes in psoriasis. The odor, staining, and overall messiness with coal tar may make less desirable than other therapies. A major advantage with tar is lack of skin thinning.
- Anthralin is available for topical use as a cream, ointment, or paste. The stinging, possible irritation, and skin discoloration may make this less acceptable to use. Anthralin may be applied for 10-30 minutes to psoriatic skin.
What oral medications are available for psoriasis?
Oral medications include acitretin (Soriatane), cyclosporine, apremilast (Otezla), and others. Oral prednisone (corticosteroid) is generally not used in psoriasis and may cause a disease flare if administered.
- Acitretin (Soriatane) is an oral drug used for certain types of psoriasis. It is not effective in all types of the disease. It may be used in males and females who are not pregnant and not planning to become pregnant for at least three years. The major side effects include dryness of skin and eyes and temporarily elevated levels of triglycerides and cholesterol (fatty substance) in the blood. Blood tests are generally required before starting this therapy and are needed periodically to monitor triglyceride levels. Patients should not become pregnant while on this drug and usually avoid becoming pregnant for at least three years after stopping this medication.
- Cyclosporine is a potent immunosuppressive drug used for other medical uses, including organ transplantation. It may be used for severe, difficult-to-treat cases of widespread psoriasis. Improvement and results may be very rapid in onset. It may be hard to get someone off of cyclosporine without flaring their psoriasis. Because of the potential cumulative toxicity, cyclosporine should not be used for more than one to two years for most psoriasis patients. Major possible side effects include kidney and blood-pressure problems.
- Methotrexate is a common drug used for rheumatoid arthritis, and it has been used effectively for many years in psoriasis. It is usually given in small weekly doses (5 mg-25 mg), either orally or by injection. Blood tests are required before and during therapy. The drug may cause liver and lung damage. Close physician monitoring and monthly to quarterly visits and labs are generally required.
- FDA has recently approved a new oral drug, apremilast (Otezla), to treat psoriasis and psoriatic arthritis, and it has an entirely novel mode of action and does not require intensive laboratory monitoring.
What injections or infusions are available for psoriasis?
The newest category of psoriasis drugs are called biologics. All biologics work by suppressing certain specific portions of the immune response that are overactive in psoriasis. Available biologic drugs include adalimumab (Humira), infliximab (Remicade), etanercept (Enbrel), ustekinumab (Stelara), and secukinumab (Cosentyx). Newer drugs are in development and available in the near future. As this class of drugs is fairly new, ongoing monitoring and adverse effect reporting continues and long-term safety continues to be monitored.
A recently approved biologic product for adults who have a moderate to severe form of psoriasis is ustekinumab. Ustekinumab is a laboratory-produced antibody that treats psoriasis by blocking the action of two proteins (interleukins) that contribute to the overactive skin inflammation.
Some biologics are to be administered by self-injections for home use while others are given by intravenous infusions in the physician's office. Biologics have some screening requirements such as a tuberculosis screening test (TB skin test or PPD test) and other labs prior to starting therapy. As with any drug, side effects are possible with all biologic drugs. Common potential side effects include mild local injection-site reactions (redness and tenderness). There is concern of serious infections and potential malignancy with nearly all biologic drugs. Precautions include patients with known or suspected hepatitis B infection, active tuberculosis, and possibly HIV/AIDS. As a general consideration, these drugs may not be an ideal choice for patients with a history of cancer and patients actively undergoing cancer therapy. In particular, there may be an increased association of lymphoma in patients taking biologics. It is not at all certain if this association is directly caused by these drugs. In part, this is because it is known that certain diseases like rheumatoid arthritis or psoriasis may be associated with an inherent increase in the overall risk of some infections and malignancies.
Biologics are expensive medications ranging in price from several to tens of thousands of dollars per year per person. Their use may be limited by availability, cost, and insurance approval. Not all insurance drug plans may fully cover these drugs for all conditions. Patients need to check with their insurance and may require a prior authorization request for coverage approval. Some of the biologics manufacturers have patient-assistance programs to help with financial issues. Therefore choice of the right medication for your condition depends on many factors, not all of them medical. Additionally, convenience of receiving the medication and lifestyle may the choice of the right biologic medication.
Currently, the main classes of biologic drugs for psoriasis are
- TNF (tumor necrosis factor) blockers,
- drugs that interfere with interleukin chemical messengers of inflammation.
TNF blockers include etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira). TNF-alpha blocking drugs may have an advantage of treating psoriatic arthritis and psoriasis skin disease. Their disadvantage is that some patients may notice a decrease in the effectiveness of TNF-alpha blocking drugs over months to years.
TNF blockers are generally not used in patients with demyelinating (neurological) diseases like multiple sclerosis, congestive heart failure, or patients with severe overall low blood counts called pancytopenia.
The major side effect of this class of drugs is suppression of the immune system. Because of the increased risk of infections while on these drugs, patients should promptly report fevers or signs of infection to their physicians. Other side effects have included autoimmune conditions like lupus or flares in lupus. Additionally, it is best to avoid any live vaccines while using TNF blockers.
- Etanercept is a self-injectable medication for home use. It is injected via a small needle just under the skin, called subcutaneous injection. It is usually dosed once or twice weekly by patients at home after training with their physician or the nursing staff. Sometimes a higher loading dose is used for the first 12 weeks and then it is "stepped down" to half the dose after the first 12 weeks. Etanercept has the advantage of at least 16 years of clinical use and long-term experience.
- Infliximab is an intravenous (IV) medication strictly for physician office or special infusion medical center use. It is dosed specifically based on the patient's weight. It is currently not for home use or self-injection. It is infused slowly over time via a small needle into a vein. After a six-week loading period, it is infused every two months. There have been reports of antibodies to this drug in patients taking it for some time. These antibodies may cause a greater drug-dose requirement for achieving disease improvement or failure to improve. The IV route may be more time-consuming, requiring physician during the infusions. Remicade has the advantage of fast disease response and good potency.
- Adalimumab is a self-injectable medication for home use. It is injected via a small needle just under the skin as a subcutaneous dose. It is usually dosed once every other week, totaling 26 injections in one year. Dosing is individualized and should be discussed with a physician. Sometimes a higher loading dose is used for the first dose (80 mg) and then it is continued at 40 mg every other week. It may give results as soon as one to two weeks of therapy. Humira has the advantage of at least 11 years of clinical use and long-term experience.
Drugs that interfere with interleukin mechanisms
- Ustekinumab is a biologic injectable medication used to modulate the immune system. It is an interleukin-12/23 human monoclonal antibody. Ustekinumab targets chemical messengers in the immune system involved in skin inflammation and skin-cell production. This drug is dosed subcutaneously (just under the skin) once a quarter (every three months). It has been very promising with very good clearance rates in the clinical trials. A major advantage may be the convenience of a quarterly medication. The concerns for infection and malignancy may be similar to the other biologics.
- Secukinumab produces a high rate of clearance and is given monthly after an induction period.
Is there a psoriasis diet?
Most patients with psoriasis seem to be overweight. Since there is a predisposition for those patients to develop cardiovascular disease and diabetes, it is suggested strongly that they try to maintain a normal body weight. Although evidence is sparse, it has been suggested that slender patients are more likely to respond to treatment.
Although dietary studies are notoriously difficult to perform and interpret, it seems likely that a diet whose fat content is composed of polyunsaturated oils like olive oil and fish oil is beneficial for psoriasis. The so-called Mediterranean diet is an example.
What about light therapy for psoriasis?
Light therapy is also called phototherapy. There are several types of medical light therapies which include PUVA (an acronym for psoralen + UVA), UVB, and narrow-band UVB. These artificial light sources have been used for decades and generally are available in only certain physician's offices. There are a few companies who may sell light boxes or light bulbs for prescribed home light therapy.
Natural sunlight is also used to treat psoriasis. Daily short, controlled exposures to natural sunlight may help or clear psoriasis in some patients. Skin unaffected by psoriasis and sensitive areas such as the face and hands may need to be protected during sun exposure.
There are also multiple newer light sources like lasers and photodynamic therapy (use of a light activating medication and a special light source) that have been used to treat psoriasis.
PUVA is a special treatment using a photosensitizing drug and timed artificial-light exposure composed of wavelengths of ultraviolet light in the UVA spectrum. The photosensitizing drug in PUVA is called psoralen. Both the psoralen and the UVA light must be administered within one hour of each other for a response to occur. These treatments are usually given in a physician's office two to three times per week. Several weeks of PUVA is usually required before seeing significant results. The light exposure time is gradually increased during each subsequent treatment. Psoralens may be given orally as a pill or topically as a bath or lotion. After a short incubation period, the skin is exposed to a special wavelength of ultraviolet light called UVA. Patients using PUVA are generally sun sensitive and must avoid sun exposure for a period of time after PUVA. Common side effects with PUVA include burning, aging of the skin, increased brown spots called lentigines, and an increased risk of skin cancer, including melanoma. The relative increase in skin cancer risk with PUVA treatment is controversial. PUVA treatments need to be closely monitored by a physician and discontinued when a maximum number of treatments have been reached.
Narrow-band UVB phototherapy is an artificial light treatment using very limited wavelengths of light. It is frequently given daily or two to three times per week. UVB is also a component of natural sunlight. UVB dosage is based on time and exposure is gradually increased by as tolerated. Potential side effects with UVB include skin burning, premature aging, and possible increased risk of skin cancer. The relative increase in skin cancer risk with UVB treatment needs further study but is probably less than PUVA or traditional UVB..
Sometimes UVB is combined with other treatments such as tar application. Goeckerman is a special psoriasis therapy using this combination. Some centers have used this therapy in a "day care" type of setting where patients are in the psoriasis treatment clinic all day for several weeks and go home each night.
Recently, a laser (excimer laser XTRAC) has been developed that generates ultraviolet light in the same range as narrow-band ultraviolet light. This light can be beneficial for psoriasis localized to small areas of skin like the palms, soles, and scalp. It is impractical to use in in extensive disease.
Is there a cure for psoriasis?
No, psoriasis is not currently curable. However, it can go into remission and show no signs of disease. Ongoing research is actively making progress on finding better treatments and a possible cure in the future.
What kind of doctor treats psoriasis?
Dermatologists specialize in the diagnosis and treatment of psoriasis, and rheumatologists specialize in the treatment of joint disorders and psoriatic arthritis. Many kinds of physicians may treat psoriasis, including dermatologists, family physicians, internal medicine physicians, rheumatologists, and other medical doctors. Some patients have also seen other allied health professionals such as acupuncturists, holistic practitioners, chiropractors, and nutritionists.
It is now apparent that patients with psoriasis are prone to cardiovascular disease. It is very important for all patients with psoriasis to be carefully monitored by their primary-care providers for heart and blood vessel disease.