Psoriasis: Treatment Options to Manage Your Symptoms & Skin
Medically reviewed by L. Anderson, PharmD. Last updated on Jan 18, 2019.
Psoriasis Uncovered: Myths Versus Truths
Myth: Psoriasis is just "dry" skin.
Truth: Psoriasis is an immune disorder leading to skin inflammation (redness, irritation and swelling) with itching and thick, dry, scales on the skin. It cause embarrassment and distress for patients.
Myth: Psoriasis is contagious.
Truth: You cannot "catch" psoriasis from someone else, even if you come into contact with their skin. It is not an infectious disease.
Myth: Psoriasis can be cured.
Truth: Psoriasis is a chronic condition that has no cure; however, there are many effective treatments, and ongoing research for this condition is active.
What is Psoriasis? It's More Than Skin Deep
Psoriasis is a chronic (long-term) autoimmune disease in which the cells of your skin are replaced at an unusually fast rate -- skin cells are quickly replaced every few days, instead of every 3 to 4 weeks. Due to this rapid turnover, extra skins cells cause raised silvery plaques that can be flaky, red, and itchy.
Psoriasis tends to occur in adults most frequently, and the symptoms may come and go.
There is no cure for psoriasis, but advanced medications allow roughly 80% to 90% of patients to have successful treatment to lessen symptoms and improve the appearance of the plaques.
What Does Psoriasis Look Like?
Psoriasis can occur on any area of the body, including hands, feet, elbows, scalp or genitals.
- In plaque psoriasis, the most common form of psoriasis, the skin tends to be dry, flaky, itchy, red and covered with white scales.
- Psoriasis can affect small areas of the body or be very widespread.
- For many people, psoriasis can lead to embarrassment, self-consciousness, or stress; some people may require treatment for depression or anxiety.
- Family doctors, dermatologists, or rheumatologists may treat your psoriasis depending upon site and severity.
The Heartbreak: What Are the Causes of Psoriasis?
The exact causes of psoriasis are not fully known. Many researchers believe it is a combination of factors -- including a family history, a faulty immune system, and effects from the environment.
- In people with psoriasis, certain white blood cells that normally fight off infection instead attack healthy cells (this is known as an autoimmune disease). It is the most prevalent autoimmune disease in the U.S.
- New skins cells are formed too quickly and result in a layer of dead, scaly skin and white blood cells that remain on the top layer of skin instead of sloughing off.
- These patches of skin and lesions are known as psoriatic lesions or plaque psoriasis.
Who Gets Psoriasis? It's Not All in the Family.
Psoriasis is the most common autoimmune disease in the U.S.; about 2.2 percent of the population, roughly 7.5 million people, have psoriasis.
- Men and women both get psoriasis equally, and it most commonly appears in adults in two age ranges -- from age 20 to 30 or from age 50 to 60. Children can also get it, although it is primarily a disease of adults.
- About 30 percent of people that develop psoriasis may also develop psoriatic arthritis, a type of rheumatoid arthritis that tends to affect the joints of the hands and feet.
- Some, but not all, patients will have a family history of psoriasis.
- Remember, psoriasis is not contagious; you cannot catch it from someone else.
Is There More Than One Type of Psoriasis?
There are many different types of psoriasis, and some may occur at the same time. Examples of different types of psoriasis include:
- Plaque Psoriasis: Most common form that causes raised, red skins areas that may be itchy or flaky.
- Guttate Psoriasis: May be a past history of streptococcal infection; may occur in children or younger adults. Small plaques form on the midsection of the body.
- Pustular Psoriasis: Painful and severe form of psoriasis, with pus-filled sacs in the psoriasis plaques that can break. Fever may occur.
Additional Types of Psoriasis, Continued
Examples of other types of psoriasis include:
- Inverse Psoriasis: This psoriasis may affect skin fold areas such as the genital area, under the breast or arms, or around the groin area. The lesions are flat, red, and often without scales.
- Nail Psoriasis: Nails may become yellow-brown, pitted, flake away or detach from the nail bed.
- Psoriatic Arthritis: May occur in up to 30 percent of patients with psoriasis; symptoms include swelling of the knees, ankles, hands and toe joints; pain; and may be accompanied by nail psoriasis.
Flare Ups: Common Psoriasis Triggers
Certain events or substances may worsen your psoriasis or cause it to come out of remission. It is best to avoid any trigger you identify that may cause a flare-up of your psoriasis. Common triggers include:
Treatments for Psoriasis: Where Do I Begin?
Treatment can lessen the formation of the excessive cells and help to return your skin to a smoother appearance. Treatments may include:
- topical creams or lotions
- phototherapy (light therapy) with or without certain medications
- prescription drugs that may be taken by mouth
- injectable medications can be used by the patient at home or given in the doctor's office.
The First Line of Therapy - Topical Corticosteroids
Mild to moderate psoriasis is initially treated with a low to mid-potency corticosteroid cream, lotion, spray or ointment - such as:
Lower potency products, such as fluocinolone (Synalar, Derma-Smooth) can be use on the face or other sensitive areas.
Lotions or foams are best for the scalp, creams are best for oozing lesions, and ointments can treat dry, raised, or scaly lesions.
Higher potency topicals are reserved for thicker, tough-to-treat areas like elbows or knees. Topical treatments work best on mild and smaller areas of psoriasis.
Topical Corticosteriods - Safety and Side Effects
Even though topical corticosteroids such as creams or ointments are applied to the surface of the skin, they can still cause side effects.
Long-term or excessive use can lead to thinning of the skin, irritation, dryness, or changes in skin color. If your doctor recommends that you occlude your psoriasis areas -- wrapping them in plastic after applying a topical corticosteroid to boost the effect -- side effects may be more common. Do not do this unless directed by your doctor.
More serious side effects may occur with topical corticosteroids if used in high doses for prolonged periods. You may become resistant to the helpful effects of topical corticosteroids over time, too.
For a complete list of side effects, please refer to the individual drug monographs.
Use of OTC Emollients and Creams
Topical emollients and creams are agents that sooth and soften the skin. Emollients are rich in fats and oils such as lanolin. They work by moisturizing the skin and protecting it from drying. Regular use of emollients may lessen the need for anti-inflammatories like corticosteroids in psoriasis.
These preparations are available over-the-counter (OTC) without a prescription - common examples include:
Ask your dermatologist, family doctor, or pharmacist for their top recommendations.
Vitamin D Analogues: How They Help
Vitamin D analogues are used to help control overactive skin cell production by binding to the vitamin D receptors on the skin cells.
Topical vitamin D analogues such as:
are effective at slowing the growth of the skin cells and can be used with emollients and topical corticosteroids applied to the skin.
The most common side effect with these agents is mild skin irritation. Some topical vitamin D analogues may take up to 6 to 8 weeks for their full effect.
Oral calcitriol (Rocaltrol) can also be used for psoriasis.
Topical Retinoids: Vitamin A Derivatives
Tazarotene topical (Tazorac) is a vitamin A derivative that affects epidermal cell growth (in the top layer of skin) in psoriasis.
- Tazarotene comes in a cream or gel and is used primarily for mild to moderate psoriasis.
Acitretin (Soriatane) is an oral retinoid that comes in capsule form and is used for severe forms of psoriasis that do not respond to other treatments.
- Test for liver enzymes and blood lipids will need to be followed.
- Noticeable improvements may take up to 2 months; the full effect might take 3 to 6 months.
- Acitretin capsules can cause severe birth defects.
Pregnancy and Breastfeeding Warnings
These vitamin A derivatives are NOT to be used when you're pregnant or planning a pregnancy due to the risk for possible severe birth defects. There is no information regarding the presence of tazarotene in human milk, but because of the possible risk to the fetus, discuss the use of tazarotene with your doctor BEFORE you start breastfeeding. DO NOT breast-feed while using acitretin.
Phototherapy: Lighten Your Symptoms
Light therapy may be used if topical treatments are not effective. Natural sunlight or ultraviolet light (UVA or UVB) can be used to help clear the skin of psoriasis lesions. Light therapy may be used alone or in combination with medications.
- Ultraviolet light lessens the growth of plaques, redness, swelling and itching.
- Methoxsalen (Oxsoralen-Ultra) can be used with UV light also (called PUVA) and is effective in treating larger areas of widespread psoriasis.
- Laser light (UVB) is also used and can directly target psoriasis and avoid the surrounding skin.
- Light therapy can increase the risk of skin burns and cancer and should not be used in people with a history of skin cancer.
Topical Coal Tar: An Old Stand-By
Coal tar is one of the oldest known treatments for psoriasis. Coal tar products are effective in treating mild to moderate psoriasis with few side effects, but can be messy with a pungent odor, and leave stains on clothes and other fabrics.
The exact way that coal tar treats psoriasis is not known. Coal tar can be found over-the-counter in shampoos, creams and lotions and can be used in combination with corticosteroids and emollients to soften the skin. It is also combined with ultraviolet-B (UVB) light in a treatment known as Goeckerman treatment. Coal tar increases the skin's absorption of UVB light for an added effect.
Heads Up: Anthralin for Scalp Psoriasis
- Anthralin, like coal tar, can be messy, stain fabrics, and has a strong odor.
- Anthralin can also stain the skin or hair with a temporary reddish brown color.
- Treatment may be applied for short periods to help lessen staining and irritation. Follow your healthcare providers instructions for use.
Like coal tar, anthralin may be used in combination with UV light to help with skin symptoms of psoriasis, including dryness, redness, flaking, scaling, and itching.
Salicylic Acid: A Keratolytic
Salicylic acid is available in both over-the-counter and prescription strengths and loosens dead skin from the psoriasis plaque to reduce scaling (keratolytic). Salicylic acid (Salacyn, Keralyt) is available in many different OTC formulations to treat both skin and scalp psoriasis.
- Salicylic acid can be used in combination with other treatments, like corticosteroid creams, anthralin, or coal tar to increase effectiveness.
- It may take up to several days before your symptoms improve.
- Common side effects of salicylic acid may include skin irritation, peeling, rash, or blanching of the skin area.
Methotrexate (MTX): A Longer-Term Option
Methotrexate (brand names: Rheumatrex, Trexall, Otrexup, Rasuvo), a folic acid antagonist, comes as a weekly oral tablet or injection that suppresses the immune system to slow down skin cell turnover.
- MTX can be used long-term for moderate to severe psoriasis and for psoriatic arthritis, but results with MTX may not be seen for several months.
- Your doctor may also prescribe folic acid in addition to MTX to help lessen stomach side effects.
- MTX can be toxic to the liver; lab monitoring will be needed.
- MTX should NOT be used in women who are pregnant or planning a pregnancy; men should also stop its use 3 months before conception.
Cyclosporine: A Short-Term Option
Cyclosporine, like methotrexate, acts to suppress the immune system to decrease skin cell turnover and growth.
Cyclosporine can increase the risk for infections, and use for greater than one year is not recommended.
- Some healthcare professionals will suggest that patients take a "holiday" from cyclosporine, use other treatments in the interim, and then return to cyclosporine therapy again later.
- This may help to lessen severe side effects like kidney damage or high blood pressure.
- Cyclosporine can be used in combination with emollients; improvement is usually seen in 2 weeks; but stabilization with cyclosporine may take 12 to 16 weeks.
Biologics and Biosimilars for Psoriasis and Psoriatic Arthritis
Biologics or biosimilars, types of personalized and targeted medicine, are increasingly being used to treat psoriasis. Biologics are usually reserved for use after other trials of medication have failed or are not tolerated. Biologics are complex protein-based drugs derived from living cells (microorganisms, plants, or animal cells) and synthesized in a laboratory.
There are 13 biologics and 7 biosimilars approved for the treatment of psoriasis, psoriatic arthritis, or both. Classes of biologics used include: tumor necrosis factor alpha (TNF-alpha) inhibitors, interleukin (IL) blockers (IL-17, IL-23, IL-12/23), and T-cell blockers.
Prior to starting a biologic, patients must be screened for tuberculosis (TB). Some biologics can be given at home via a pen for subcutaneous injection, while some treatments require an office visit for IV injection. Treatments can costs several thousand dollars per month, and may increase the risk for certain types of infections, including tuberculosis (TB). The manufacturer may be able to help with costs through their Patient Assistance Program.
The next slide outlines the biologics with access to their drug monographs.
FDA-Approved Biologics for Psoriasis and Psoriatic Arthritis
Approved to treat both psoriasis and psoriatic arthritis:
- adalimumab (Humira) and the biosimilars adalimumab-atto (Amjevita), adalimumab-adbm (Cyltezo, and adalimumab-adaz (Hyrimoz)
- certolizumab (Cimzia)
- etanercept (Enbrel) and the biosimilar etanercept-szzs (Erelzi)
- infliximab (Remicade) and the biosimilars: infliximab-dyyb (Inflectra), infliximab-abda (Renflexis), and infliximab-qbtx (Ixifi)
- ixekizumab (Taltz)
- secukinumab (Cosentyx)
- ustekinumab (Stelara)
Approved to treat psoriasis:
Approved to treat psoriatic arthritis:
The Latest Treatments: Otezla (apremilast)
Otezla (apremilast) is a phosphodiesterase 4 (PDE4) inhibitor approved by the FDA for plaque psoriasis and psoriatic arthritis. Exactly how Otezla works is not fully known. Studies show that Otezla blocks the enzyme PDE4 to lower inflammation in the body, and improvement in psoriasis may begin within the first few weeks of treatment. Otezla is not a biologic agent.
Otezla is taken as a tablet by mouth, and you will gradually increase your dose of Otezla over the first 5 days to help lower the possibility of stomach upset. After the initial gradual dose increase, Otezla is taken twice a day, morning and night. Those with severe kidney disease will take Otezla only once a day.
The most common side effects with Otezla in plaque psoriasis studies were diarrhea, nausea, upper respiratory tract infection, tension headache, and headache.
The IL-17 Blockers: Siliq, Taltz, and Cosentyx
In February 2017, the FDA approved Siliq (brodalumab) injection, an anti-interleukin-17-receptor monoclonal antibody (blocks IL-17) from Valeant Pharmaceuticals to treat adults with moderate-to-severe plaque psoriasis.
In three randomized, placebo-controlled studies with 4,373 patients, more Siliq-treated patients had clear or almost clear skin compared to placebo-treated patients.
However, serious warnings exist with this product. Suicidal ideation and behavior, including completed suicides, occurred in patients treated with Siliq during trials, but a direct causal association has not been determined. Due to this possible risk, a restricted access program is in place that includes:
- a Boxed Warning
- the Siliq REMS Program
- a Medication Guide
Taltz (ixekizumab) and Cosentyx (secukinumab) are also IL-17 blockers. Taltz and Cosentyx are both approved for plaque psoriasis and psoriatic arthritis, but these agents do not have a suicide boxed warning or a restricted access REMS program in palce, as with Siliq.
All three products are given by subcutaneous (under the skin) self-injection.
First-In-Class Agent: Tremfya
Tremfya is a first-in-class biologic that blocks IL-23, a cytokine that plays a key role in inflammation and symptoms of plaque psoriasis. Tremfya is given as a 100 mg subcutaneous (under the skin) self-injection. The recommended dose is 100 mg at Week 0, Week 4, and every 8 weeks thereafter.
In clinical studies, patients receiving Tremfya had significant improvement in the clearance of their skin plaques and a larger improvement in itching, pain, stinging, burning and skin tightness when compared with placebo at week 16. Superior results in skin clearance compared with Humira (adalimumab) were shown at weeks 16, 24 and 48. Common side effects may include lung infections, headache, reactions at the injection site, and joint pain, among others.
Another IL-23 blocker, Ilumya (tildrakizumab-asmn) was approved in March of 2018, also for plaque psoriasis. Ilumya has an advantage over Tremfya in that it is given only every 12 weeks (instead of 8) after initial loading at week 0 and week 4. It is also given by subcutaneous self-injection.
In two Phase III clinical studies, 926 patients received Ilumya or placebo. The primary efficacy endpoints, defined as at least 75% of skin clearance and Physician's Global Assessment score of "clear" or "minimal" at week 12 after two doses, were met in both studies.
Don't Let Psoriasis Settle: Fight Back
While psoriasis may be a lifelong and chronic condition, medications can make a dramatic improvement in skin lesions and one's sense of well-being. That is - no more fears to show a little skin; your embarrassment is dramatically lessened and your self-confidence boosted.
However, medications for psoriasis are some of the newest treatments on the market and it's important you understand their use and side effects.
- Join force with other patients who share your same condition and have similar concerns.
- Ask questions of other group members, voice concerns, and stay up the with latest psoriasis news, all in the Drugs.com Psoriasis Q&A Center and Support Groups. There is always power in numbers!
Finished: Psoriasis: Treatment Options to Manage Your Symptoms and Skin
- Moderate to Severe Psoriasis and Psoriatic Arthritis: Biologic Drugs. National Psoriasis Foundation. Accessed Jan 18, 2019 at https://www.psoriasis.org/about-psoriasis/treatments/biologics
- FDA Approves Ixifi. Drugs.com. Accessed Jan 18, 2019 at https://www.drugs.com/newdrugs/fda-approves-ixifi-infliximab-qbtx-biosimilar-remicade-4659.html
- FDA Approves Renflexis. Drugs.com. Accessed Jan 18, 2019 at https://www.drugs.com/newdrugs/fda-approves-renflexis-infliximab-abda-biosimilar-remicade-4519.html
- FDA Approves Cyltezo. Drugs.com. Accessed Jan 18, 2019 at https://www.drugs.com/newdrugs/fda-approves-cyltezo-adalimumab-adbm-biosimilar-humira-4583.html
- FDA Approves Amjevita (adalimumab-atto), a Biosimilar to Humira. Drugs.com. Accessed Jan 18, 2019 at https://www.drugs.com/newdrugs/fda-approves-amjevita-adalimumab-atto-biosimilar-humira-4434.html
- New Results From Second Phase 3 Study Show Significant Efficacy of Guselkumab and Superiority Versus Humira in Treatment of Moderate to Severe Plaque Psoriasis. Clinical Trials. Drugs.com. Accessed Jan 18, 2019 at https://www.drugs.com/clinical_trials/new-results-second-phase-3-study-show-significant-efficacy-guselkumab-superiority-versus-humira-17546.html
- American Academy of Dermatology. Clinical Guidelines. Psoriasis. Guidelines of care for the management of psoriasis and psoriatic arthritis. Accessed Jan 18, 2019. http://www.aad.org/education/clinical-guidelines
- National Psoriasis Foundation. Psoriasis. Topical steroids potency chart. Accessed Jan 18, 2019. http://www.psoriasis.org/about-psoriasis/treatments/topicals/steroids/potency-chart
- National Psoriasis Foundation. Topical treatments for psoriasis, including steroids. Accessed Jan 18, 2019. http://www.psoriasis.org/
- Mayo Clinic. Psoriasis. Accessed Jan 18, 2019. http://www.mayoclinic.com/health/psoriasis/DS00193
- UpToDate. Patient Information: Psoriasis (Beyond the Basics). Accessed Jan 18, 2019. http://www.uptodate.com/contents/psoriasis-beyond-the-basics
- Otezla Product Labeling. Celgene Corporation. Accessed Jan 18, 2019 at http://www.celgene.com/content/uploads/otezla-pi.pdf
Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.