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Psoriasis: Pictures, Symptoms & Drug Treatment Options

Medically reviewed by Leigh Ann Anderson, PharmD. Last updated on Jan 14, 2021.

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Psoriasis Uncovered: Myths vs 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.
  • See more pictures of psoriasis.

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 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.
  • Psoriasis can lead to feelings of embarrasment, self-consciousness, and worry.

Who Gets Psoriasis?

Psoriasis is the most common autoimmune disease in the U.S. About 2 to 3 percent of the population, or roughly 8 million people, have psoriasis, according to the National Psoriasis Foundation.

  • Men and women both get psoriasis equally, and it most commonly appears in adults in two age ranges -- between 20 to 30 years of age or from 50 to 60 years of age. 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? Yes.

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.

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:

  • Illnesses or infections
  • Skin injuries or burns
  • Stressful situations or anxiety
  • Cold weather, smoke or smoking
  • Heavy alcohol use
  • Certain medications such as lithium, high blood pressure medications (beta blockers), drugs to prevent malaria, and iodide products, such as potassium iodide and sodium iodide.

Treatments for Psoriasis: Where Do I Begin?

There are many different treatments for psoriasis, and what you use may differ depending upon severity, previous treatments, psoriasis type and what your preferences are, including costs.

Treatment can lessen the formation of the excessive skin 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 F/S) 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, such as lanolin, are rich in fats and oils. 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.

Calcipotriene with betamethasone is a vitamin D analogue that is already combined with an antiinflammatory corticosteroid. Brands include: Taclonex, Taclonex Scalp, Wynzora and Enstilar.

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 capsules) can also be used for psoriasis.

Topical Retinoids: Vitamin A Derivatives

Tazarotene (Tazorac) is a vitamin A derivative that affects epidermal cell growth (in the top layer of skin) in psoriasis and exhibits some anti-inflammatory action. It is also available as a generic option.

  • Tazarotene comes in a cream or gel (0.05% or 0.1% strengths) and is used primarily for mild to moderate psoriasis. Tazorac is also approved for acne treatment.
  • Other brands of tazarotene, approved for other uses, include Arazlo (acne), Fabior (acne) and Avage (used for to reduce fine wrinkles, dark spots or freckles on the face.)
  • In 2019, a combination of halobetasol, a topical corticosteroid, and tazarotene (brand: Duobrii Lotion) from Bausch Health was FDA-approved for plaque psoriasis.

Acitretin (Soriatane) is an oral retinoid, also a form of vitamin A, that comes as a capsule (10 mg, 25 mg strengths).

  • It is used for severe forms of psoriasis that do not respond to other treatments. Acitretin is not a cure for psoriasis, and your psoriasis may come back after you stop taking this medication.
  • It is also available as a generic option.

Pregnancy and Breastfeeding Warnings

Important: View the patient counseling information for Tazorac or Soriatane to learn more about the Contraindications and Warnings for Use in pregnancy and breastfeeding and discuss this information with your doctor.

The vitamin A derivatives tazarotene (Tazorac) and acitretin (Soriatane) are NOT to be used when you're pregnant or planning a pregnancy due to the risk for possible severe birth defects. You should not be pregnant when you start treatment or become pregnant during treatment. In addition, these products should not be used during breastfeeding. Before you start treatment with either medicine, talk to your doctor about the risks of pregnancy and breastfeeding with these medicines.

In addition, you must NOT become pregnant while taking acitretin (Soriatane) and for at least 3 YEARS after stopping acitretin, so that the drug can be eliminated to below a blood concentration that would be associated with an increased incidence of birth defects.

Phototherapy: Lighten Your Symptoms

Light therapy (phototherapy) 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. These 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. However, it does increase the skin's absorption of UVB light for an added effect.

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 used with ultraviolet-B (UVB) light in a treatment known as Goeckerman treatment.

  • Goeckerman treatment is a course of UV light therapy combined with coal tar for more moderate-to-severe plaque psoriasis.
  • It is messy and smelly, but can be effective; however, not many doctors offer this treatment The regimen is usually given daily over several weeks at a time.

Heads Up: Anthralin for Scalp Psoriasis

Anthralin (Drithocreme, Zithranol Shampoo) is a prescription topical cream or shampoo for the scalp that slows down the growth of skin cells.

  • 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 (Salitop, Keralyt) is available in both over-the-counter and prescription strengths. It's known as a "keratolytic", which means it loosens dead skin from the psoriasis plaque to reduce scaling.

Salicylic acid is available in many different OTC formulations, such as lotions, gels, creams, foams, shampoos and others, 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: RediTrex, Trexall, Otrexup, Rasuvo), is a folic acid antagonist, meaning it blocks the action of folic acid. Methotrexate is often abbreviated "MTX".

  • Methotrexate comes as a once-weekly oral tablet or injection that suppresses the immune system and DNA synthesis 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. Review MTX dosing here.
  • Your doctor may also prescribe folic acid in addition to MTX to help lessen stomach and other side effects.
  • MTX can be toxic to the liver and other organs; 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. Use effective contraception during and after treatment with methotrexate.

  • Effective birth control is recommended for females of reproductive potential during therapy and for at least 6 months after the final dose.
  • Effective contraception is recommended for males with female partners of reproductive potential during therapy and for at least 3 months after the final dose of methotrexate.

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

Biologics or biosimilars are types of personalized and targeted medicine that are increasingly being used to treat psoriasis.

  • Biologics are usually reserved for use after other trials of medication have failed or are not tolerated.
  • These are complex protein-based drugs derived from living cells (microorganisms, plants, or animal cells) and synthesized in a laboratory.

There are many biologics and 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 may lead to serious side effects, so be sure to discuss this with your doctor. They may increase the risk for certain types of infections, including tuberculosis (TB).

These agents can costs several thousand dollars per month if you are paying cash. However, the manufacturer may be able to help with costs through their Copay Cards or Patient Assistance Program. Check with your insurance company for their preferred products and to determine your copay if you have insurance.

The next slide outlines the biologics with access to their product information.

FDA-Approved Biologics for Psoriasis and Psoriatic Arthritis

Approved to treat both plaque psoriasis and psoriatic arthritis:

Approved to treat plaque psoriasis:

Approved to treat psoriatic arthritis:

Otezla (apremilast)

Otezla (apremilast) is a phosphodiesterase 4 (PDE4) inhibitor approved by the FDA in 2014 for plaque psoriasis and psoriatic arthritis.

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, but its exact mechanism is not known. Otezla is not classified as a biologic agent.

Otezla dose (in more detail)

  • 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.
  • Otezla can be taken with or without food. Do not crush, split, or chew the tablets.
  • Those with severe kidney disease will take Otezla only once a day. Your dose will also be lowered during the graudual dose increase.

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 interleukin-17 inhibitors approved for plaque psoriasis, psoriatic arthritis and ankylosing spondylitis. However, unlike Siliq, Taltz and Cosentyx do not have a suicide boxed warning or a restricted access REMS program requirement.

All three products are given by subcutaneous (under the skin) self-injection.

First-In-Class Agent: Tremfya

In July 2017, Janssen’s Tremfya (guselkumab) gained FDA- approval for treatment of moderate-to-severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy. In July 2020, it was approved for psoriatic arthritis treatment.

  • Tremfya is a first-in-class biologic that blocks IL-23, an interleukin cytokine that plays a key role in inflammation and symptoms of 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.
  • When used for psoriatic arthritis, Tremfya may be given alone or in combination with a non-biologic disease-modifying antirheumatic drug (DMARD) like methotrexate.
  • Common side effects may include upper respiratory tract infections, headache, injection site reactions, joint pain, bronchitis, diarrhea, gastroenteritis, skin fungal infections, and herpes simplex infections.

A second IL-23 blocker, Ilumya (tildrakizumab-asmn) was approved in March of 2018 for plaque psoriasis. It is not currently approved for psoriatic arthritis, like Tremfya.

  • Ilumya has an advantage over Tremfya in that it is given only every 12 weeks (instead of 8) after an initial loading dose at week 0 and week 4. The patient may give by subcutaneous self-injection.
  • The most common (≥1%) side effects with Ilumya treatment are upper respiratory tract infections, injection site reactions, and diarrhea.

Don't Let Psoriasis Win: 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 means no more fears to show a little skin; your embarrassment is dramatically lessened and your self-confidence is 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. Always follow the advice and direction of your health care provider.

Finished: Psoriasis: Pictures, Symptoms & Drug Treatment Options

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Sources

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  • FDA Approves Ixifi. Drugs.com. Accessed Jan 14, 2021 at https://www.drugs.com/newdrugs/fda-ap20oves-ixifi-infliximab-qbtx-biosimilar-remicade-4659.html
  • FDA Approves Renflexis. Drugs.com. Accessed Jan 14, 2021 at https://www.drugs.com/newdrugs/fda-approves-renflexis-infliximab-abda-biosimilar-remicade-4519.html
  • FDA Approves Cyltezo. Drugs.com. Accessed Jan 14, 2021 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 14, 2021 at https://www.drugs.com/newdrugs/fda-approves-amjevita-adalimumab-atto-biosimilar-humira-4434.html
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  • National Psoriasis Foundation. Psoriasis. Topical steroids potency chart. Accessed Jan 14, 2021. http://www.psoriasis.org/about-psoriasis/treatments/topicals/steroids/potency-chart
  • National Psoriasis Foundation. Topical treatments for psoriasis, including steroids. Accessed Jan 14, 2021. http://www.psoriasis.org/
  • Mayo Clinic. Psoriasis. Accessed Jan 14, 2021. http://www.mayoclinic.com/health/psoriasis/DS00193
  • UpToDate. Patient Information: Psoriasis (Beyond the Basics). Accessed Jan 14, 2021. http://www.uptodate.com/contents/psoriasis-beyond-the-basics
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Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.