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Treatment of psoriasis has come a long way in recent years. Why? The medical community started to take the condition more seriously.
“Forty to 50 years ago, psoriasis was considered a cosmetic condition, but that’s changed in the last 10 to 15 years,” said Alex Ortega Loayza, MD, an assistant professor of dermatology at Oregon Health & Science University in Portland. Primary care providers can begin treating mild psoriasis, but most people need a specialist. A dermatologist treats psoriasis alone, and a rheumatologist treats psoriatic arthritis.
“The severity of the disease is going to guide the treatment,” Dr. Ortega said. “If more than 10 percent of the body surface area is involved, we consider that severe psoriasis.” Less than three percent is mild psoriasis and five to 10 percent is moderate. If you have joint pain too, you may have psoriatic arthritis. Approximately 30 percent of psoriasis patients have psoriatic arthritis, and many don’t know they have it.
Psoriasis is an autoimmune condition, so many treatments work by suppressing your immune system—but immunosuppression increases the risk of infections, so it’s important to learn the risks of your treatment options. Here’s what you need to know about different treatment options for psoriasis and how to choose the best treatment for you.
Topical medications
For mild to moderate psoriasis, most treatment plans begin with topical medications in the form of creams, gels, sprays, shampoos, foams, solutions and lotions. You might use several of these at once or combine them with other treatments.
Over-the-counter topical treatments include salicylic acid and coal tar, but consult your healthcare provider before using any. Fragrance-free moisturizers with aloe or jojoba may help soothe your skin, and creams with capsaicin can help with itching. Shampoos with zinc pyrithione help reduce dandruff.
Prescription topical medications include steroidal creams, vitamin D creams and other non-steroidal treatments. Steroid creams, among the most common first-line treatments for psoriasis, reduce inflammation, redness and swelling. But they’re typically not used long-term, and stopping them suddenly can cause flare-ups.
Phototherapy
Light therapy, or phototherapy, targets the skin inflammation that causes your red, scaly, itchy flare-ups.
“It’s sometimes underused, but phototherapy can be very effective with severe psoriasis,” Ortega said.
Phototherapy exposes the affected skin to ultraviolet rays. UVB rays are most effective, delivered in short doses at your healthcare provider’s office. (Home units exist, too.) Don’t get discouraged when you start—phototherapy often makes psoriasis worse before it gets better; it should improve as you continue therapy. Those with severe psoriasis may take oral medications in addition to phototherapy.
UVA light only helps if paired with psoralen, a medication that increases the skin’s light sensitivity. Psoralen with UVA, called PUVA, works best for guttate psoriasis, plaque psoriasis and psoriasis on your palms and foot soles.
The newest phototherapy approved by the U.S. Food and Drug Administration is the excimer laser, a high-intensity beam of UVB light directed at specific, localized patches of affected skin, especially on the scalp.
You can use the sun for phototherapy, too, but not tanning beds. Tanning beds mostly emit UVA light and increase the risk of skin cancer. If you use sunlight, protect the rest of your skin from sunburn and ask your healthcare provider for a treatment plan, especially since some psoriasis medications make it more likely you’ll burn.
Systemic therapies
If topical treatments and phototherapy don’t control your psoriasis, it’s time to consider one of the traditional systemic therapies that have been around for a decade or more. Most of these are oral medications—one can be an injection—that can take anywhere from two weeks to eight to 16 weeks to begin working, depending on the drug. They tend to take somewhere between three and six months to achieve their best results.
Which therapy you try first will depend on your personal situation (such as whether you plan to conceive soon), your medical history (some aren’t recommended with certain pre-existing conditions), your insurance, your provider’s clinical experience and judgment, your specific symptoms and your tolerance of side effects.
While very effective, all systemic therapies are immuno-suppressive and can involve substantial side effects and risks that you should discuss with your healthcare provider before you start taking them. Some drugs require ongoing monitoring and blood tests to ensure you don’t experience liver damage or other problems.
Those who are pregnant, breastfeeding, allergic, have certain medical conditions or taking certain medications cannot take some of these drugs, so make sure your healthcare provider knows your medical history. This treatment comparison chart provides dosages and side effects for these drugs and off-label options.
New oral treatments
Most systemic therapies have been in use for years, but the FDA has recently approved several new ones, with more likely on the way. These long-term medications work by blocking enzymes that control inflammation in your cells. One treats both psoriasis and psoriatic arthritis. Another is currently only approved for rheumatoid arthritis, but several studies suggest it’s effective for plaque psoriasis too.
The newer systemic therapies tend to have fewer or less severe side effects and risks as the older ones and don’t take the same toll on your liver. However, it’s still important to ask your healthcare provider about these drugs’ side effects and risks before starting them.
Biologics
Providers might prescribe you a biologic drug after trying the systemic ones or might skip straight to biologics, depending on your symptoms and what your insurance company allows. Biologics are proteins that block certain T cells or proteins in the immune system that cause skin or joint inflammation. Since biologics are made from living cells, your provider administers the drug as an injection or through an IV.
The FDA has approved about a dozen biologics for psoriasis or psoriatic arthritis. Each has different side effects, but all carry a risk of infection and irritation at the injection site. Some involve rare, but serious risks such as blood or nervous system disorders or certain cancers.
A small percentage of people develop resistance to a biologic over time. “We don’t know why some people develop resistance and some people don’t,” Ortega said. “We can then switch biologics or add other medications that help control the disease as well.”
What’s right for you?
The right therapy for you depends on you and your symptoms and often involves trial and error. Your healthcare provider considers your age, sex, occupation, resources and likelihood of sticking with a treatment.
“It’s not only about the medication. It’s also about compliance,” Ortega said. Every treatment has side effects, so ask your healthcare provider what to expect and say something if the side effects become unbearable.
“Three months is a good time frame to see if the patient is responding to treatment,” Ortega said, though you might stop a drug early because of side effects.
In his practice, Ortega sees 75 percent improvement in symptoms in about 60 to 70 percent of his patients. A small percentage are very difficult to treat, but more treatment options are always on the way. The National Psoriasis Foundation tracks all drugs in development for psoriasis and psoriatic arthritis.
“Treatments are getting better and better all the time,” Ortega said. “With personalized medicine,” Ortega said, “we’ll have the resources to find out which medication will work best with which patient.”
