skin disorders

Psoriasis Treatments

While there is no cure for psoriasis, that doesn’t mean you can’t do anything about it! Psoriasis can be managed—and even go into periods of remission—with treatment. The key is finding the treatment that works best for you.

In This Article:

Psoriasis is a chronic, inflammatory immune system disorder that affects the skin of millions of Americans. So far, there is no cure for the red, inflamed lesions that come with psoriasis, but that doesn’t mean there isn’t anything you can do about them! Psoriasis can be managed—and even go into periods of remission—with treatment. The key is finding the treatment that works best for you, which for some may take months, if not years.


Topical Treatments

The number of options for managing psoriasis continues to grow as new research emerges. In this article we detail some of the most common treatments, from topical options all the way up to injectable medications. Keep in mind that not every treatment works for everyone, and that it’s important to find a dermatologist who specializes to determine the severity of the disorder and prescribe what might work best. The list of topical treatments includes, but is not limited to, those listed below.

Phototherapy/Sunlight: This may seem contradictory to the usual warnings about avoiding prolonged, unprotected sun exposure, but extended periods of time in the sun (also referred to as "climatotherapy") can significantly improve, or even clear, psoriasis. In fact, some research indicates that 60% of those who use this kind of treatment obtain relief at least for some period of time. Ultraviolet (UV) light from the sun suppresses the skin’s immune response and, therefore, reduces that type of inflammation, slowing the overproduction of skin cells that causes the scaling. Daily, short, non-burning exposure to sunlight clears or improves psoriasis in many people. Therefore, sunlight may be included among the initial treatments for the disorder. Of course, this convenient, inexpensive treatment has serious drawbacks, including advanced skin aging, far greater risk of skin cancer, and an impaired immune response that can cause other health problems. [1,2]

UVB lamps: An alternative to natural sunlight is medically supervised exposure to narrow-band ultraviolet B (UVB) lamps. UVB light is used when topical treatments have failed, or in combination with topical treatments. The short-term risks of using controlled narrow-band UVB exposure to treat psoriasis is minimal, and long-term studies of large numbers of patients treated with narrow-band UVB have not demonstrated an increased risk of skin cancer, suggesting that this treatment may be far safer than sunlight. Narrow-band UVB lamps are safer than natural sunlight because they do not emit ultraviolet A (UVA) light and because users can better control the range of UVB impact. Sunlight emits both UVA and UVB radiation; the UVA light is considered more dangerous and there is a great deal of research indicating that UVA is the main cause of skin cancer and skin aging. Narrow-band UVB treatments are considered one of the most efficacious and cost-effective therapies for moderate to severe psoriasis. This type of therapy is generally effective for 2/3 of psoriasis patients. [3,4]

It is important to point out that most of the tanning beds or sun beds found in salons or spas are fitted with UVA bulbs that emit only minimal UVB radiation. Unfortunately, these are widely used by those with psoriasis, but they are only minimally effective in treating it, while presenting the dangers of UVA exposure.

UVB-emitting lasers: A relatively new treatment for psoriasis is lasers that emit narrow-band UVB light. It can clear skin lesions faster than direct sunlight or UVB lamps. Approximately 70% of psoriasis patients who receive this treatment are almost completely free of lesions after 10 sessions. UVB lasers work by initiating the death of T-cells, rendering them unable to trigger the immune system to signal rapid cell proliferation, which is the cause of psoriasis. The most well-known laser for psoriasis is the 308-nanometer (nm) excimer laser. It emits a single wavelength, and, unlike the light from UVB lamps, the excimer laser light can be focused solely on psoriatic lesions, thus sparing the surrounding healthy skin from radiation. Because it can be precisely focused, the UVB light from the laser can be used at a strength six times that of the UVB lamp radiation. The result? Better clearance of psoriasis lesions with fewer treatments; typically 4–10 sessions for the UVB laser, compared with 25–30 sessions for UVB lamp treatments. [5]

Pulsed dye lasers: Pulsed dye lasers (PDL) have a successful treatment history for psoriasis, with 585nm being the most common wavelength used. The light emitted by these devices targets the blood vessels contributing to the formation of lesions. Extended clearance of lesions is a common outcome for many psoriasis patients undergoing PDL treatments, but not all lesions respond in the same way. For example, you may get great results on your arm or elbow, but see only minimal improvement in facial lesions. This inconsistency is attributed to differences in the underlying (dermal) pattern of blood flow that affects each lesion. In general, larger and redder lesions respond less favorably than lighter ones. Despite this news, the excimer laser is still the best choice for successful treatment of psoriasis lesions. [6]

Coal tar: Treating psoriasis with coal tar is a very old option that is not used as frequently as it once was. This topical medication is available both over-the-counter and by prescription; the determining factor being the potency and amount of coal tar the medication contains. Coal tar inhibits the substances in skin that trigger rapid cell proliferation, thus reducing the appearance and severity of psoriasis. [7] Coal tar can be combined with other psoriasis medications (like topical steroids) or with sunshine (UV light). However, coal tar can make the skin more sensitive to UV light, and extreme caution is advised when you combine coal tar use with UV therapy (or exposure to the sun) to avoid a severe burn or skin damage. Other negative aspects of using coal tar are the irritation, the smell, and its tendency to stain clothes.

Anthralin or dithranol: Similar to coal tar, anthralin (also called dithranol) is a topical, paste-like prescription medication that has been used to treat psoriasis for decades. It works best in cases of mild to moderate psoriasis. Although the specific activity of anthralin on skin is not completely understood, it appears to inhibit cell proliferation and can be very effective in treating psoriasis. It is often used in combination with other treatments. [8] Anthralin has few serious side effects, but can cause extreme irritation or burn the normal-appearing skin surrounding the psoriatic lesions. Similar to coal tar, anthralin stains on contact. There are a variety of regimens for its use, but the negative side effects limit its appeal.

Vitamin D analogues: Multiple studies have demonstrated impressive improvement in psoriatic lesions with topical application of calcipotriene (trade name Dovonex), a derivative of vitamin D3, when used alone or in combination with other therapies. Note: calcipotriene is not the same compound as the vitamin D found in commercial vitamin supplements or added to food products such as milk or cereal.

Calcipotriene not only inhibits cell proliferation and enhances cell differentiation in the skin of patients with psoriasis, but also appears to affect the substances in skin that generate the increased production of cells. In several well-designed, short-term studies in adults, the efficacy of calcipotriene ointment (50 micrograms, twice daily) was similar or superior to the efficacy of several other anti-psoriatic agents in adult patients with mild to moderate psoriasis. Calcipotriene generally was well tolerated in short- and long-term studies in adult patients, with the major side effect being irritation. Given calcipotriene’s compatibility with other psoriasis treatments, it is valuable as a first- or second-line therapy option for severe psoriasis. [9,10,11] Other forms of vitamin D3 creams include calcitriol and tacalitol.

Topical corticosteroids: Cortisone creams have been used for years as the first step in treating psoriasis and are available in a wide variety of textures (from ointments to gels) and concentrations. Cortisones reduce inflammation, itching, and, potentially, slow skin cell proliferation, and often are used in combination with other psoriasis treatments. [12] However, the more powerful the corticosteroid, the higher the risk of more severe side effects, which include burning, irritation, dryness, acne, thinning of the skin (with long-term use), dilated blood vessels, and loss of skin color. Less potent topical steroids are often used for mild to moderate psoriasis; the high-potency versions are reserved for more severe conditions.

An effective regimen of high-potency cortisones, such as halobetasol (Ultravate), is to use it daily until the psoriasis plaque flattens out, after which the medication is applied only on weekends. Another high-potency corticosteroid, mometasone (Elocon), is administered only once per day, and is as effective (or possibly more effective) as other corticosteroids while presenting a lower risk of severe side effects. These very potent drugs present a small risk of hormonal problems for a period of time after the drug has been withdrawn. The larger the area treated with corticosteroids, the higher the risk, especially if the area is covered by heavy material or is bandaged. Also, in most cases, resistance to these drugs eventually develops.

Topical retinoids: Prescription retinoids such as Tazorac (active ingredient tazarotene) have been shown to have a positive effect on plaque psoriasis, particularly in combination with other treatments. The manner in which retinoids work is similar to that of potent topical steroids, but with the advantage of a longer period of relief during treatment and no detrimental side effects or damage to skin.

Salicylic acid: Often called beta hydroxy acid (BHA), salicylic acid is sold over-the-counter in strengths of 1.8% to 3%; however, treatment for psoriasis often requires a strength of 6%, which is available only by prescription. Because BHA is an exfoliant, it can soften and help remove the scaly skin layers of psoriatic lesions.


Systemic Treatments

Researchers do not know with certainty exactly what causes psoriasis, but they agree that it’s an overactive immune system disorder. Systemic treatments work by targeting the immune system (often in an immuno-suppressant capacity). These treatments are prescription medications that usually are prescribed for people who have moderate to severe psoriasis. Some of the best-known systemic medications include:

  • Methotrexate: Methotrexate is an immune-modulating drug known for its ability to reduce the uncontrolled overproduction of cells. It works by binding to an enzyme involved in the rapid growth of cells, and slowing the overproduction of skin cells that leads to psoriasis. The most frequent adverse effects of methotrexate therapy are abnormal liver function test results, nausea, and gastric complaints. The most feared adverse effects are liver damage and the suppression of bone marrow activity. The liver problems associated with methotrexate are related to a high cumulative dose; therefore, alternating the types of therapy or using methotrexate only intermittently instead of continuously reduces that risk. Methotrexate is not recommended for women who are or plan to become pregnant.
  • Cyclosporin (trade name Neoral): A strong immuno-suppressant drug, cyclosporin acts by reducing inflammation in the skin and reducing cell proliferation by blocking the immune factors (T-cell lymphocytes) that are likely causing the problem. The FDA approved cyclosporin for psoriasis in 1997, with the proviso that it not be used for more than one year at a time. Studies have shown cyclosporin to be highly effective and well tolerated for the short-term treatment of severe psoriasis, including on the nails. However, this medication has serious side effects, including such temporary effects as headaches, gingivitis, joint pain, gout, body-hair growth, tremors, high blood pressure, kidney problems, and fatigue. The National Toxicology Program’s Eighth Report on Carcinogens warns that cyclosporin is "known to be a human carcinogen based on studies in humans." You and your doctor must weigh and carefully consider all of these factors before deciding on this course of treatment.
  • Acitretin (Soriatane) and isotretinoin (formerly known as Accutane and now prescribed as a generic) are oral retinoids. Acitretin is similar to isotretinoin, but acitretin is the only retinoid approved by the FDA for use in the treatment of psoriasis; isotretinoin is approved by the FDA for use in treating acne. How retinoids work in the treatment of psoriasis is not completely understood, although they are thought to block the overproduction of skin cells. Neither of these retinoids are to be used if a woman is pregnant because all systemic retinoids present a strong risk of causing birth defects.


Biologic Treatments

Biologics are a relatively new category of treatment for psoriasis. According to the National Psoriasis Foundation (NPF), biologics differ from systemics in that they target specific areas of the immune system instead of the entire immune system. Biologics largely work by blocking the action of T-cells or blocking specific proteins in the immune system. The following are among the more common biologics approved for use for psoriasis:

  • Etanercept (trade name Enbrel): The anti-tumor medication Etanercept appears to be a promising agent that can be used in combination therapy for the treatment of psoriasis. Six months of treatment (one or two injections per week) typically leads to significant improvement in psoriasis symptoms.
  • 5-fluorouracil (brand name Efudex): Chemotherapy agents such as 5-fluorouracil may be effective in the treatment of psoriasis affecting the nails. Psoriatic-affected nails are quite common for those with psoriasis—up to 50% of those with psoriasis also have it on their nails.
  • Infliximab (trade name Remicade): Used to treat Crohn’s disease and rheumatoid arthritis, Infliximab also is used to manage some forms of psoriasis, and often shows excellent results within 2 weeks. The most serious side effects are reactivation of tuberculosis in patients who have had this illness and the potential development of lymphomas. Although a clear causative factor has not been established (and there is the possibility that the lymphoma is the result of the inflammatory process that causes psoriasis), the theory is that immune-suppressive drugs such as Infliximab "provide a biologic basis for concern and justification for the initiation of additional epidemiological studies to formally evaluate this possible association." It is best to consult with your doctor about the potential risks of this drug before beginning treatment, based on your medical history.
  • Alefacept (trade name Amevive): This drug works by reducing the number of immune-activated T-cells in the skin, thus significantly reducing the major cause of psoriasis. It is administered by a physician via weekly injections for a period of 12 weeks. The treatments are suspended after 12 weeks to observe changes in the skin. If the results are positive (meaning symptoms regress), further treatment is not needed until the symptoms return. Remissions of up to seven months are not uncommon.
  • Adalimumab (trade name Humira): Initially approved to treat rheumatoid arthritis, adalimumab works by blocking TNF-alpha, a protein that prompts the body to create inflammation. Studies have shown that psoriasis patients have an excess production of TNF-alpha in their skin. [13]
  • Apremilast (trade name Otezla): One of the newest treatments approved for psoriasis, apremilast is an oral medication considered a “small-molecule” treatment, meaning it selectively targets molecules within immune cells, thus affecting the inflammation processes within the cell. [14]


Combination Therapy

PUVA: The most typical combination therapy for psoriasis is the prescription medication Psoralen with exposure to UVA light (PUVA). Psoralen, which can be taken orally as a pill or applied topically, makes the skin more sensitive to UVA light with a wavelength of 320–400 nanometers (nm). This combination suppresses the production of abnormal skin cells. PUVA can eliminate or dramatically reduce psoriatic lesions for the majority of people who use it, and there is evidence it can provide extended remissions. [15] The catch? Psoralen and UVA light are carcinogenic and phototoxic. Getting rid of psoriasis can mean a lot, but putting your skin at risk for premature aging and cancer may be trading one problem for another.

PUVA therapy brings with it an increased risk of a type of skin cancer known as squamous cell carcinoma, especially for those who have fair skin and have more than 200 treatments (not an unheard of number given that even with treatment, psoriasis is a chronic skin disorder). Despite large-scale international studies, evidence about whether or not PUVA therapy increases the risk of malignant melanoma (the most serious form of skin cancer) is inconclusive.

Given the risks, PUVA should be considered only for extreme or disabling psoriasis, and only after other treatments have failed. Although the risks to skin are considerable, it should be noted that compared to UVB phototherapy, PUVA treatments were shown (in a 100-person randomized study) to clear psoriasis symptoms in a greater number of patients and with fewer treatments (16 PUVA treatments versus 25 UVB treatments). In addition, six months after treatment, 35% of the PUVA-treated psoriasis patients were still in remission, compared with only 12% of the UVB-treated psoriasis patients.

All of the above treatments are often used in varying combinations for the best results. Frequently, several combination treatments are used in rotation to reduce the potentially harmful side effects of each. Determining if any of these treatments will work for you, alone or in combination, takes patience and a systematic, ongoing review and evaluation of the appearance of your skin and of your overall health. Successful treatment requires diligent adherence to the regimen and a realistic understanding of what you can and can’t expect. It also is important to be aware of the consequences and potential side effects of the varying treatment levels, which you should discuss with your physician.

For more information on the current status of available treatments, visit the National Psoriasis Foundation (NPF) website: www.psoriasis.org

References Cited:

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  3. National Psoriasis Foundation. Phototherapy. [Internet] [cited 2015 October] Available from: https://www.psoriasis.org/about-psoriasis/treatments/phototherapy
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  10. Kim G. The Rationale Behind Topical Vitamin D Analogs in the Treatment of Psoriasis. Where Does Topical Calcitriol Fit In? J Clin Aesthet Dermatol. 2010 Aug; 3(8): 46–53.
  11. Soleymani T, Hung T, Soung J. The role of vitamin D in psoriasis: a review. Int J Dermatol. 2015; 54(4):383–92.
  12. Uva L, Miguel D, Pinheiro C, Antunes J, Cruz D, et al. Mechanisms of Action of Topical Corticosteroids in Psoriasis. Int J Endocrinol. 2012: 561018.
  13. National Psoriasis Foundation. Moderate to Severe Psoriasis and Psoriatic Arthritis: Biologic Drugs. [Internet] [cited 2015 October] Available from: https://www.psoriasis.org/about-psoriasis/treatments/biologics
  14. National Psoriasis Foundation. New Oral Treatments. [Internet] [cited 2015 October] Available from: https://www.psoriasis.org/about-psoriasis/treatments/oral-treatments
  15. Situm M, Bulat V, Majcen K, Dzapo A, Jezovita J. Benefits of controlled ultraviolet radiation in the treatment of dermatological diseases. Coll Antropol. 2014 Dec; 38(4):1249–53.
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