How Psoriasis Is Treated

Psoriasis is a chronic condition that can't be cured but can be effectively treated, usually with a combination of self-care interventions that can be done at home, over-the-counter or prescription topical medications, prescription drugs that are taken by mouth or injection, and light therapy, in which ultraviolet rays are directed on skin lesions. Managing psoriasis can be tricky though: There are several degrees of severity of psoriasis, as well as different types, and not all respond to the same interventions. What's more, the location of psoriasis lesions can dictate what treatments will work (or not).

Topical Prescriptions

These are drugs that are applied directly to the skin to treat only a specific area. Your doctor may recommend that you use a topical option alone or in conjunction with another prescription medication, an over-the-counter treatment, or phototherapy, all of which are described below.

Corticosteroids

Topical steroids reduce inflammation and soothe skin; increase the rate at which skin cells renew; rein in the overactive immune system; and help skin to peel, which in turn unclogs pores. They come in a variety of forms and are, in part, prescribed based on the severity and location of lesions.

These include ointments (greasy, but potent); creams (best for the face, groin, or armpits); oils that can be used on the entire body or as an overnight scalp treatment; gels and foams (easy to apply to the scalp and hairy areas); and sprays—in particular, a quick-acting spray called Clobex (clobetasol).

Corticosteroids also come in a medicated tape that adheres to skin and is especially effective on thick plaques that tend to build up on elbows and knees.

Topical steroids have a number of potential side effects, depending on what part of the body they're used on. Around the eyes, they can cause damage that leads to glaucoma or cataracts. On the face, a too-strong steroid can cause acne, rosacea, or the formation of tiny red blood vessels called telangiectasia. These drugs can also cause large red stretch marks to develop on the groin or in the armpits, and also cause the skin to become thin. These side effects tend to be permanent.

Psoriasis on the palms and soles (palmoplantar psoriasisoften requires extra potent medication because the skin in these areas is so thick. Ingredients designed to dissolve flakes and enhance penetration of the medications can be compounded into topical creams and ointments to make them more effective for hands and feet. One effective combination, which can be made by prescription, includes a strong topical steroid (such as clobetasol) along with a solution of salicylic acid and coal tar. Although messy and smelly, this combination is quite effective for thick, stubborn palmoplantar psoriasis.

Vitamin D Analogs

Psoriasis medications derived from vitamin D work by decreasing the rate of skin cell growth. They do the job slowly—it can take four to six weeks to see results—but have none of the side effects of topical steroids. A commonly-prescribed vitamin D analog is Dovonex (calcipotriene), which comes as a cream as well as a liquid that can be used on the scalp. 

Dovonex can be used continuously and is safe for patients who have psoriasis on up to 20 percent of their body. It can be combined with other treatments, including topical steroids and phototherapy. 

Calcineurin Inhibitors

Also known as immune-modulating drugs, medications such as Protopic (tacrolimus) and Elidel (pimecrolimus) reduce inflammation without the side effects of steroids. The FDA has only approved these drugs for treating atopic dermatitis, so prescribing them for psoriasis is considered off-label use. However, they're especially useful for treating sensitive areas such as the face, groin, and skin folds.

A potential and unusual side effect of both Protopic and Elidel is that skin where the drug has been applied can become red and hot to the touch if you drink alcohol. Call your doctor right away if you have any side effects that are persistent or if you experience serious reactions such as swollen glands, fever, fatigue, cold sores, or oozing or swelling of the skin.

Also, note that both Protopic and Elidel have black box warnings due to a possible link to skin cancer and lymphoma. However, studies have not found enough evidence to support this connection, so the American Academy of Dermatology and others have taken the stand that there is no proof that these medications cause cancer and that they are safe and effective when used appropriately.

Psoriatec (Anthralin)

This modern version of anthralin, once the gold standard of psoriasis treatment, is less messy than its predecessor—a paste that was applied thickly to plaques and then dusted with a powder. Psoriatec is a timed-release cream, meaning the active ingredient is released slowly into the skin. Not only does this make it neater and easier to use than old-school anthralin, it helps to minimize skin irritation and staining.

To use Psoriatec, apply it to affected areas of skin, wait about 30 minutes, and then take a cool shower. This will remove the cream without activating the time-released drug. After that, you can take a warm water shower with soap. Psoriatec can also be applied to the scalp before shampooing.

Other advantages of this medication: It doesn't contain steroids, so it will not cause thinning of skin or stretch marks. It's also less expensive than some newer psoriasis treatments. 

Topical Retinoids

Retinoids, which are derived from vitamin A, enter the cell membranes of keratinocytes, the main type of cells found in the skin. There they alter the transcription of certain genes, which decreases inflammation, abnormal cell growth and skin cell division, and abnormal maturation of skin cells.

A common example is Tazorac (tazarotene) which often is prescribed to treat mild plaque psoriasis (psoriasis that covers less than 10 percent of the body and doesn’t involve any sensitive areas of the body, such as the genitals). It also can be used to treat nail psoriasis.

Tazorac is available as a cream, a gel, or a foam. Common side effects of tazarotene include itching, redness, and burning, but only in areas where the cream is applied. To reduce irritation, consider trying a lower concentration (per a revised prescription from your doctor); using a moisturizer along with the medication; applying the drug every other day, or leaving it on the skin for 30 to 60 minutes and then wiping it off.

Usually, Tazorac works best when combined with other psoriasis medications and also can be used along with phototherapy to make it more effective.

Systemic Prescriptions

Systemic medications are taken by mouth or injected. Unlike topical prescriptions, which target a specific area of skin, these options treat the entire body. They, too, may be used alone or in conjunction with other treatments.

Oral Retinoids

For people with moderate to severe psoriasis (who have lesions covering more than 10 percent of their skin or who have debilitating symptoms in addition to a rash), an oral retinoid such as Soriatane (acitretin) is sometimes prescribed. 

Soriatane may be particularly effective for people with certain types of psoriasis, including psoriasis affecting the palms and soles; nail psoriasis; pustular psoriasis; and erythrodermic psoriasis. Another group who may benefit from acitretin are people with immunosuppression who aren't good candidates for biologics and other drugs such as methotrexate that work, in part, by suppressing the immune response. 

Soriatane often works best combined with other treatments, such as phototherapy or topical treatments. Unlike other oral medications for psoriasis, Soriatane can safely be taken along with biologic drugs. However, it should not be used with another retinoid product, because this might lead to vitamin A toxicity.

Note, too, that oral retinoids can cause severe birth defects and should never be used during pregnancy. Women who are expecting or trying to conceive should not use Soriatane. In fact, women who are prescribed this medication are required to take two pregnancy tests before beginning treatment, use two forms of birth control while on the drug, and have a monthly pregnancy test as well.

Biologics

Biologic drugs are protein-based medications that are derived from living cells cultured in a laboratory. Rather than affecting the entire immune system, biologics "block the action of a specific type of immune cell called a T cell, or block proteins in the immune system, such as tumor necrosis factor-alpha (TNF-alpha), interleukin 17-A, or interleukins 12 and 23," according to the National Psoriasis Foundation (NPF).

There are many types of biologics for treating psoriasis. All are given by injection. Adults can give themselves these shots; children will need to be injected by a medical professional. Biologics are considered very safe for most people and are the most effective treatments for moderate to severe psoriasis. If you're prescribed a biologic medication, you can expect to see improvement in your symptoms within three or four months.

Among the biologic medications used for psoriasis are Enbrel (etanercept), Humira (adalimumab), Remicade (infliximab), Stelara (ustekinumab), Cosentyx (secukinumab), and Tremfya (guselkumab.

PDE4 Inhibitors

Otezla (apremilast) is an oral medication that was approved by the FDA for treating moderate to severe plaque psoriasis in early 2014. It is recommended for people who aren't getting results from topical treatments and who are good candidates for candidates for phototherapy and systemic drugs.

According to the NPF, Otezla works by targeting an enzyme known as phosphodiesterase 4 (PDE4), leading to improved regulation of inflammation signaling within cells. Since it comes in pill form, it may be preferable for people who are squeamish about giving themselves injections of biologics.

Antibiotics

When guttate psoriasis, which is characterized by a rash made up of teardrop-shaped lesions, is triggered by an infection such as strep throat, antibiotics will be a necessary part of treatment. Besides an antibiotic to clear up the infection, a person with guttate psoriasis will require relief from itching and discomfort from the rash. Sometimes a moisturizer will be all it takes to protect and soothe skin, but if itching is especially problematic, a topical steroid may be necessary.

Over-the-Counter Therapies

Over-the-counter medications often are used in combination with prescription medications. However, be aware that OTC treatments can have side effects when used together with prescription drugs. Be sure to talk to a doctor about how to use OTC remedies before adding them to your comprehensive treatment plan.

Hydrocortisone Cream

Often an over-the-counter hydrocortisone cream is a key player in the first line of defense against mild psoriasis. It works by blocking chemicals in the brain that cause the itch response by inhibiting the body's inflammatory reaction and constricting blood vessels.

The possible side effects of corticosteroids include burning at the application site, changes in the color of the affected skin, acne, and a temporary increase in itching.

Note as well that this type of medication isn't recommended for all body parts. The skin in the genital area is very thin, for example, which can allow excessive amounts of medication to be absorbed and cause thinning or atrophy (the wasting away of tissue). A prescription topical cream called Vytone, which combines hydrocortisone with an antibiotic called iodoquinol, is sometimes a good choice for the delicate skin of the genitals.

Anti-Itch Medications

Many OTC and prescription products for treating psoriasis may relieve itching, soothe inflammation, and improve scaling and general skin health. When itching isn't helped by other treatments, you may want to try products specifically formulated for this symptom, such as:

  • Antihistamines—medications used to treat allergies that target the nerve pathways linked to itching. Some versions, such as Benadryl (diphenhydramine), have a sedative effect, which may help if itching interferes with sleep.
  • Anti-itch creams that are sold over the counter typically contain menthol or camphor, or non-prescription strength benzocaine or hydrocortisone. 

Salicylic Acid Products

Salicylic acid is classified as a keratolytic. As such, it works by dissolving scales and flakes so 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 reducing psoriasis scales, salicylic acid makes it easier for topical medications to sink deeply into the skin. Your doctor can prescribe a stronger one if it's clear this ingredient will work better for you in a more potent concentration.

Coal Tar

Coal tar products for psoriasis have been around for more than a century. Coal tar is the byproduct of coal processing and distillation. Medicinal coal tar works by relieving inflammation and slowing skin cell growth and turnover, which ultimately will thin out psoriatic plaques. It takes about eight weeks for coal tar to have this effect

The U.S. Food and Drug Administration (FDA) has approved products containing up to 5 percent coal tar as safe and effective for treating psoriasis. The side effects of coal tar are minimal. Sometimes it causes some skin irritation and redness.

Note that greater concentrations are classified as carcinogenic (cancer-causing) by the World Health Organization's International Agency for Research on Cancer, but there have been no significant studies linking coal tar to cancer.

You can find coal tar in a variety of lotions, creams, bath solutions, and scalp treatments. Sometimes a doctor will prescribe a combination of coal tar and another ingredient, such as salicylic acid, which can be mixed by a compound pharmacist. It's usually left on the scalp or skin for a couple of hours and then rinsed off. 

Medicated Shampoos 

Scalp psoriasis can be particularly difficult to treat. Since the plaques are on the scalp, hair can get in the way of topical medications. The answer often is to use a shampoo that contains salicylic acid, tar, or both. Such shampoos are available both over the counter or, for stubborn scales, by prescription.

To get the most benefits from either, use a comb while shampooing to gently loosen plaques (but don't dig or pick—this can cause bleeding and even hair loss.) A 10-day course of the prescription antifungal pill ketoconazole can be effective at temporarily clearing up stubborn scalp psoriasis, although the use of this drug for this condition is considered off-label.

Specialist-Driven Procedures

Light therapy, which involves directing ultraviolet light onto affected skin, is a highly effective way to treat psoriasis–either alone or in conjunction with topical or systemic treatments.

Phototherapy

Phototherapy, which involves exposing skin to ultraviolet (UV) energy, has immunosuppressive and anti-inflammatory effects on skin cells. It's especially effective for people who have moderate to severe psoriasis that affects large areas of the body. There are several types of phototherapy used to treat psoriasis: 

  • Broadband ultraviolet B (BB-UVB) and narrowband ultraviolet B (NB-UVB): Both broadband and narrowband UVB therapy can be given after an application of coal tar, which makes skin more sensitive to light and, thus, phototherapy more effective. This approach is known as Goeckerman therapy.
  • PUVA (psoralen plus ultraviolet A): With PUVA, skin is similarly treated with a medication called psoralen that sensitizes skin so that it will respond well to exposure to UVA rays, which aren't as strong as UVB rays.
  • Excimer laser therapy: Excimer lasers, which produce ultraviolet light at a specific wavelength that's highly effective for treating psoriasis, are used to treat small areas such as the elbow or knee where psoriasis plaques can be particularly stubborn.

A typical course of phototherapy treatment is three to five sessions a week for several weeks, followed by occasional maintenance sessions or a repeated course of treatment. Phototherapy is relatively safe, even during pregnancy, but it does have potential side effects such as burning, itching, and redness (basically the same reactions as sun exposure). These are especially likely to affect people with fair skin. Some people have also experienced nausea while having PUVA therapy.

Phototherapy also appears to increase the risk of skin cancer, particularly squamous cell cancer. This risk is highest for people who get PUVA therapy over an extended period of time, but it is possible that UVB therapy might also increase one’s risk. People who aren't good candidates for phototherapy include those who:

  • Have a history of a photosensitivity disorder
  • Take photosensitizing medications
  • Have a history of melanoma
  • Have certain medical conditions, like lupus
  • Are immunosuppressed (like from an organ transplant)

Home Remedies and Lifestyle

While the above options can be the biggest players in your psoriasis treatment regimen, how you care for your skin and even what you do as you go about your day can play an important role as well.

Skin Care

Establishing a daily bathing and moisturizing routine will minimize scaling as well as help relieve itching. Soak in a warm (not hot) tub for 10 to 15 minutes, using a loofah or washcloth to gently slough off loose scales. Pat—don't rub—skin dry and moisturize immediately, while skin is still damp. Daily hair washing with any mild shampoo is a good way to buff psoriasis plaques from the scalp.

When choosing a moisturizer to treat psoriasis, zero in ingredients that will be most helpful for you. Some to look for and how they work:

  • Emollients resemble lubricants that the skin makes naturally. Examples: shea butter; cocoa butter; animal-based oils such as mink, emu, and lanolin; mineral oils; and plant oils
  • Water-binding agents help to maintain the concentration of moisture in the skin. Examples: collagen, elastin, lecithin, amino acids, proteins, glucose, fructose, sucrose, and phospholipids.
  • Anti-irritants calm inflamed skin. Examples: aloe, vitamin C, licorice root, grape extract, green tea, chamomile extract, and willow bark.
  • Antioxidants may speed up cell turnover, which in turn helps to clear psoriatic scales. Examples: selenium, vitamin A, coenzyme Q10, alpha lipoic acid, vitamin C, vitamin E, and grape extract.

To intensify the effects of a moisturizer, you can try a method called occlusion in which you slather on the product and then cover it for a period of time so it's thoroughly absorbed. If you're dealing with psoriasis on your hands, slip on cotton or plastic gloves; you can use socks or even plastic bags to cover your feet.

Itch Relief

Pruritis (itchiness) can be especially irritating, and scratching can irritate skin even more. If plaques are scraped off, it can cause pinpoint bleeding known as Auspitz sign.

One way to help ease the itch of psoriasis is to apply an ice pack to areas where it's particularly severe: The cold will numb nerve endings temporarily while also cooling raw and inflamed skin. Storing moisturizer in the fridge is another way to tap the soothing benefits of cold.

Oatmeal can treat widespread plaques by gently softening and soothing skin. You can purchase colloidal (finely ground) oatmeal bath products or make your own by whirring regular breakfast oatmeal in a food processor until powdery. Add enough to a warm bath to make the water look milky.

Injury Avoidance

Almost any kind of skin trauma can trigger a flare—a reaction called the Koebner effect—in people with psoriasis. This can include injuries such as cuts, insect bites, burns, and puncture wounds, but also shaving, manicures and pedicures, thumb-sucking, friction, medical procedures such as surgery and skin allergy patch tests, and tattoos. Avoid any of these that you can and be especially careful when doing those you want or need to do (like shaving).

Diet

Following a gluten-free diet, in which you steer clear of all foods containing wheat, barley, and rye, may help ease your psoriasis symptoms. There's been some research to suggest that certain people with psoriasis have high levels of antibodies to a component of gluten called gliadin, an indication that they're reacting to gluten in their diet (even if they haven't been diagnosed with celiac disease or non-celiac gluten sensitivity).

There needs to be a lot more research to confirm a true association between dietary gluten and psoriasis, but it does seem that for some people who have psoriasis and are then diagnosed with celiac disease, completely cutting gluten from their diet (the only way to manage celiac disease) helps ease skin symptoms. 

Beyond cutting gluten, you might also try taking a very close look at the foods you eat every day. Making sure you include plenty of fresh fruits and vegetables may be helpful—and certainly won't hurt.

Complementary Medicine (CAM)

People have tried all sorts of natural treatments for psoriasis. Very few have been proven effective, but here are two that are safe and worth asking your doctor about, if they interest you.

Capsaicin

This compound can be helpful for easing itching. It occurs naturally in chili peppers and works by affecting molecules at nerve endings that are responsible for transferring sensations of pain and itching to the brain. Capsaicin is available as a topical cream and can be found in a variety of brands, many of which are labeled to treat arthritis pain. According to the National Psoriasis Foundation (NPF), creams with 0.025% capsaicin are effective in reducing the redness, itching, and scaling associated with psoriasis.

Biotin

Biotin is a B vitamin that is often taken to make the nails grow stronger and more normally. It's sometimes used to help treat nail psoriasis. The recommended dose for this purpose is 2500 micrograms a day. As with all nail treatments, you need to be consistent with the vitamin regimen for at least three months to see the benefit (or six months in the case of toenails).

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