How Psoriasis Is Treated

Psoriasis is a chronic autoimmune disorder that cannot be cured but can be effectively treated, usually with a combination of self-care interventions, topical medications, oral or injectable immune suppressants, and ultraviolet (UV) light therapy.

Despite a plethora of treatment options, managing psoriasis can be tricky. It requires an individualized approach based on the type, location, and severity of psoriasis you have. Treatments are typically staged, utilizing conservative therapies with minimal side effects before embracing those that are more invasive or costly.

Not all people will respond to psoriasis interventions equally. Patience and persistence may be needed to find the combination of therapies that works best for you.

Psoriasis Doctor Discussion Guide

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Home Remedies and Lifestyle

Mild psoriasis can often be managed with self-care strategies that aim to mitigate the dryness, itching, and flaking of psoriatic skin plaques. In addition to skincare, there are lifestyle changes that can reduce your risk of episodic flares.

Skincare

Establishing a daily bathing and moisturizing routine will minimize scaling and relieve persistent itching. Whether you bathe or shower, you will want to avoid overheating the skin (which promotes inflammation and the risk of flares) and supersaturating the skin (which increases skin dryness).

Limit showers to five to 10 minutes, keeping the water warm rather than hot. Bathing occasionally can help remove scales, but soak for no longer than 15 to 20 minutes and avoid vigorous scrubbing.

A washcloth is usually all you need to slough loose scales. Daily shampooing is a good way to gently buff plaques from the scalp.

After showering or bathing, pat the skin dry and moisturize immediately with a fragrance-free, emollient-rich lotion. To intensify the effects of a moisturizer, cover the moisturized skin with a non-absorbent wrap (such as cling film or plastic gloves) for several hours or even overnight.

Itch Relief

Pruritis (itchiness) is an especially irritating aspect of psoriasis and can further inflame the lesions if scratched.

One way to help ease the itch is to apply an ice pack or cold compress to the affected skin. Limit treatments to no more than 15 to 20 minutes, covering the ice pack with a thin cloth and moving it around in circular motions (rather than letting it settle in one place).

Storing moisturizer in the refrigerator is a good way to tap the soothing benefits of cold.

Oatmeal baths can also reduce itching by gently softening and exfoliating the skin. You can purchase oatmeal bath products at the drugstore or make your own by whirring breakfast oatmeal in a food processor until powdery. Add enough to create a warm milky bath. Epsom salt has been known to help.

Injury Avoidance

Almost any kind of skin trauma can trigger a flare in people with psoriasis. Known as the Koebner effect, it can occur as a result of a cut, burn, abrasion, or anything that causes intense friction or inflammation. Examples include:

  • Vigorous scratching
  • Shaving with a dull blade or too little lotion
  • Wearing a tight belt with rough fabric
  • Suntanning
  • Insect bites
  • Skin allergies

While some skin injuries just happen, others can be avoided by taking the necessary precautions (such as using sunscreen or insect repellent, wearing light fabrics, or changing your razor regularly).

Over-the-Counter (OTC) Therapies

Over-the-counter (OTC) medications may provide ample relief of mild psoriasis or be used in combination with prescription medications for more severe cases. Even though you can purchase OTC products on your own, you should avoid self-treating without a proper diagnosis.

Psoriasis can mimic other diseases and vice versa. Without a proper diagnosis, you may incorrectly treat a skin condition or, worse yet, miss a more serious disease in need of immediate medical attention.

Hydrocortisone Cream

An OTC 1% hydrocortisone cream is a key player in the first-line treatment of mild psoriasis. It works by blocking inflammatory proteins, called cytokines, thereby reducing skin redness, swelling, and itch. Side effects include burning or stinging at the application site, acne, changes in skin color, and a temporary increase in itching.

Hydrocortisone cream should not be used on the face or genitals unless so directed by your doctor. Prolonged use can cause irreversible skin atrophy (thinning).

Anti-Itch Medications

In addition to hydrocortisone cream, there are a number of OTC products designed specifically to relieve itching:

  • Antihistamines work by blocking chemicals, called histamines, that trigger allergy symptoms. Some, like Benadryl (diphenhydramine), have a sedative effect, which may be useful if the itching is keeping you up at night.
  • Anti-itch creams work by temporary numbing nerve receptors in the skin. These include products made with menthol or camphor, or topical anesthetics containing benzocaine.

Salicylic Acid

Salicylic acid is classified as a keratolytic, a type of drug that helps remove excess skin. It works by dissolving scales so that they can be washed or brushed away easily.

Salicylic acid is available in a variety of OTC products, including creams, shampoos, soaps, and lotions. By removing the surface scales, salicylic acid makes it easier for topical medications to be absorbed into the skin.

Coal Tar

Coal tar has been used for more than a century to treat psoriasis and other skin conditions. It works by relieving inflammation and slowing skin cell growth. When used as prescribed, coal tar can achieve visible improvement within around eight weeks.

The U.S. Food and Drug Administration (FDA) has stated that products containing up to 5% coal tar are safe and effective for treating psoriasis.

The side effects of coal tar are minimal and may include skin irritation and redness. You can find coal tar in a variety of lotions, creams, bath solutions, and scalp treatments.

Depending on the product, the coal tar is usually left on the skin for an hour or two and then rinsed off. Coal tar has a pungent, resiny odor and can permanently stain fabrics if splashed or splattered.

Medicated Shampoo 

Scalp psoriasis can be especially difficult to treat as the hair can get in the way of topical medicines. Medicated shampoos (containing salicylic acid, tar, or both) are commonly used, either on their own or to support topical treatment.

To get the optimal benefit, massage the shampoo into the scalp and let it sit for five to 10 minutes before gently combing the hair. This can help loosen plaques without pain or bleeding.

Topical Prescriptions

Topical medications are considered the mainstay of moderate to severe psoriasis treatment. They may be used on their own or incorporated into combination therapies.

Corticosteroids

Topical corticosteroids can help reduce inflammation, aid in the shedding of skin cells, and promote the renewal of healthy skin. They come in a variety of formulations and are chosen based on the severity and location of the lesions.

Options include:

  • Ointments (greasy, but potent)
  • Creams (best for the face, groin, or armpits)
  • Oils (used on the entire body or as an overnight scalp treatment)
  • Gels and foams (easy to apply to the scalp and hairy areas)
  • Sprays (generally high-potency)
  • Infused tapes (for use on the knees or elbows)

Topical corticosteroids can cause side effects if not used as directed. Around the eyes, they can seep into tissues and cause glaucoma or cataracts. On the face, a too-strong steroid can cause acne, rosacea, and telangiectasia (spider veins). Skin atrophy and stretch marks are common when corticosteroids are overused.

Vitamin D Analogs

Psoriasis medications derived from vitamin D work by decreasing the rate of skin cell growth. They do the job slowly—taking around four to six weeks to see results—but have none of the long-term side effects of topical steroids.

Dovonex (calcipotriene) is a commonly prescribed vitamin D analog that comes in a cream or scalp solution. Dovonex can be used continuously and can be combined with other treatments, including topical steroids and phototherapy. 

Calcineurin Inhibitors

Also known as topical immune modulators, calcineurin inhibitors like Protopic (tacrolimus) and Elidel (pimecrolimus) work by blocking a chemical needed to trigger the inflammatory response. Topical calcineurin inhibitors are especially gentle and can even be applied to the face and groin.

Protopic and Elidel are approved by the FDA for the treatment of eczema but are regularly used off-label to treat all forms of psoriasis. Side effects tend to be mild and may include itching, acne, redness, burning, stinging, cold/heat sensitivity, and folliculitis.

Despite their proven benefits, the FDA issued a black box warning in 2005 suggesting that Protopic and Elidel may be linked to skin cancer and lymphoma.

For its part, the American Academy of Dermatology has adamantly stated that no causal link has been found and that the drugs are safe and effective when used as prescribed.

Topical Retinoids

Retinoids, derived from vitamin A, slow the hyperproduction of skin cells by penetrating the cellular membrane and interfering with the synthesis of DNA.

Tazorac (tazarotene) is the topical retinoid approved for the treatment of plaque psoriasis. It can be used on most parts of the body, including the nails. Tazorac is known to cause skin irritation and should only be used on the face or genitals under the direction of a dermatologist.

Tazorac is available as a cream, gel, or foam. Common side effects include application site itchiness, redness, and burning. Applying a thin layer of moisturizer beforehand may help minimize these symptoms.

Tazorac works best when combined with other psoriasis medications. It can also sensitize the skin in advance UV light therapy to achieve better results.

Psoriatec (Anthralin)

Anthralin has been around since the early 1900s and was once the gold standard of psoriasis treatment. Although it has been supplanted by more effective (and less messy) medications, anthralin is still used today if other standard medications fail to provide relief.

Psoriatec, a timed-release anthralin cream, is an updated version that can slow the hyperproduction of skin cells without a hassle, staining, or skin irritation. It is applied directly to the skin and left for 30 minutes before being washed off with cool or lukewarm water.

Psoriatec may cause redness and burning but doesn't damage the skin, even with long-term use. It is also less expensive than some of the newer psoriasis treatments. 

Systemic Prescriptions

Systemic medications are either taken by mouth or injected into the skin or a blood vessel. They are used when topical drugs are unable to control psoriasis on their own. Some temper the entire immune system, while others suppress specific parts of the immune response.

DMARDS

Disease-modifying antirheumatic drugs (DMARDs) like methotrexate and cyclosporine work by dampening the immune system as a whole. The drugs are synthesized in the lab and are typically used in the first-line oral treatment of moderate to severe plaque psoriasis.

Methotrexate can cause side effects ranging from liver toxicity to bone marrow suppression. Cyclosporine is known to cause high blood pressure, liver toxicity, and kidney impairment. Periodic blood tests are needed to avoid treatment complications.

Oral Retinoids

For people with moderate to severe psoriasis, an oral retinoid such as Soriatane (acitretin) is sometimes prescribed. Soriatane is particularly useful for people with nail psoriasis, pustular psoriasis, and erythrodermic psoriasis. Oral retinoids are also ideal for people with immunosuppression who aren't candidates for biologics (see below) or methotrexate.

Unlike other oral medications, Soriatane can be taken with biologic drugs. However, it should not be used with any other retinoid product as this may lead to vitamin A toxicity.

Soriatane is classified as Pregnancy Category X drugs and should never be used during pregnancy due to the risk of birth defects. Women in their reproductive years should use two forms of birth control while on Soriatane and take a monthly pregnancy test as well.

Biologics

Biologic drugs are medications derived from living cells cultured in a lab. Rather than affecting the entire immune system, biologics block either the white blood cells that incite the inflammatory response (called sT-cells) or specific cytokines (such as tumor necrosis factor-alpha, interleukin 17-A, or interleukins 12 and 23).

There are many types of biologics used to treat psoriasis, all of which are given by injection. They are considered safe for most people with moderate to severe psoriasis. Side effects include injection site pain, chills, weakness, diarrhea, nausea, vomiting, and rash.

When prescribed a biologic, be aware that is can take anywhere from three to four months before visible results are seen. Prior to this, you may experience a temporary worsening of psoriasis symptoms.

Among the biologic drugs used for psoriasis are:

PDE4 Inhibitors

Otezla (apremilast) is an oral medication classified as a PDE4 inhibitor. It is approved for the treatment of moderate to severe psoriasis, as well as active psoriatic arthritis.

Otezla works by blocking an enzyme known as phosphodiesterase 4 (PDE4), which promotes inflammation within cells. Side effects include diarrhea, headache, nausea, upper respiratory tract infections, vomiting, runny nose, abdominal pain, and fatigue.

Specialist-Driven Procedures

Psoriasis is not treated surgically. However, the condition does respond to sunlight and can improve significantly when exposure is limited to 10 to 20 minutes per day (with sunscreen, of course).

This same principle is used in phototherapy wherein controlled bursts of UV light can slow skin cell production and help achieve remission. Phototherapy is highly effective in treating psoriasis, either alone or in conjunction with topical or systemic drugs.

Phototherapy Types

Phototherapy has immunosuppressive and anti-inflammatory effects beneficial to people with psoriasis. It is especially useful when more than 30% of the body is affected. The phototherapy systems deliver either stronger ultraviolet B (UVB) light or weaker ultraviolet A (UVA) light as follows:

  • Broadband UVB (BB-UVB) and narrowband UVB (NB-UVB): Both of these can be used with topical coal tar, which makes the skin more sensitive to light. This approach is known as Goeckerman therapy.
  • Psoralen plus ultraviolet A (PUVA): The skin is treated with a sensitizing agent called psoralen. This is considered essential since UVA is usually too weak to be beneficial on its own.
  • Excimer laser therapy: Excimer lasers, which generate focused beams of UVB light, are used to treat smaller areas of skin, such as the elbow or knee, where psoriasis can be especially stubborn.

A typical course of phototherapy is three to five sessions per week for several weeks, followed by occasional maintenance sessions. Side effects include burning, itching, redness, and sunburn (particularly in fair-skinned people).

Phototherapy poses a slightly increased risk of skin cancer, particularly squamous cell carcinoma. This risk is highest for people who receive PUVA therapy over an extended period of time.

Phototherapy is not appropriate for people who are immunosuppressed, are taking photosensitizing medications, or have a history of melanoma, lupus, or photosensitivity disorders like erythropoietic protoporphyria.

Complementary and Alternative Medicine (CAM)

People regularly turn to natural therapies to support standard medical treatments of psoriasis. However, very few of these, including aloe vera or turmeric, have been shown to be effective in clinical research. There are exceptions.

Capsaicin

Capsaicin is a chemical derived from chili peppers that appears to block pain signals to the brain when applied topically. This can help alleviate itching and discomfort when applied to unbroken skin.

Capsaicin is sold as a topical cream or transdermal patch under various brand names.

According to the National Psoriasis Foundation (NPF), topical creams containing 0.025% capsaicin are effective in reducing the redness, itching, and scaling associated with psoriasis.

Biotin

Biotin is a B vitamin sometimes used to support the treatment of nail psoriasis. It doesn't alter the disease mechanisms that cause nail crumbling, denting, or lifting, but rather promotes normal nail growth when used with topical therapies.

The recommended dose is 2,500 micrograms (mcg) per day. It needs to be taken consistently as part of combination therapy for no less than three months (for fingernails) and six months (for toenails).

According to the National Institutes of Health (NIH), a biotin deficiency is one of the primary causes of brittle nails.

Mind-Body Therapies

Stress is a major trigger of psoriatic flares. In fact, according to a 2018 review of studies in Disease Markers, anywhere from 40% to 80% of people with psoriasis cite stress as a contributing factor.

There are a number of stress-reduction techniques that may help if practiced on an ongoing basis or during acute flares. They include:

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