Psoriasis Treatments

While there is no cure for psoriasis (an autoimmune skin condition), it is treatable and manageable. Treatment may vary depending on the psoriasis type, but the condition is frequently treated with topical treatments, oral and injected systemic (whole-body) drugs, and phototherapy.

Treatment goals for psoriasis are to decrease disease severity and improve quality of life. This typically means reducing skin lesions on most of the body within a few months of the start of treatment. Getting there requires trial and error to determine the best ways to slow down skin cell production and reduce symptom severity. 

This article will cover the different treatment options for psoriasis, choosing the right treatments, and how to best manage and treat psoriasis flare-ups.

Types of Psoriasis

Psoriasis is an autoimmune skin condition in which the immune system malfunctions and attacks healthy tissues. When this overactive response occurs, the body responds with skin inflammation that causes skin cells to grow too quickly. Psoriasis is characterized by periods of a flare-up (times of high disease activity) and remission (times of few or no symptoms). 

There are different types of psoriasis, including:

• Plaque psoriasis is the most common and causes accelerated skin cell growth that leads to plaques.
• Guttate psoriasis primarily affects children and young adults and causes small, pink or red spots on the skin.
• Inverse psoriasis affects areas near skinfolds, including the armpits, under the breasts, and in the groin area. It causes red, smooth, and shiny skin patches that worsen with sweating and friction.
• Pustular psoriasis is rare and causes pus-filled bumps and red, inflamed skin.
• Erythrodermic psoriasis—the rarest type—is very serious and causes widespread, inflamed skin that appears burnt. This psoriasis type might be a medical emergency and should be treated in a hospital.
• Psoriatic arthritis (PsA) is a type of psoriatic disease affecting the joints and the entheses, the areas where ligaments and tendons meet bone. It affects up to 30% of people with psoriasis.
• Nail psoriasis causes nail pitting, nail bed separation, nail color changes, and tenderness in the area around and below the nails. It is commonly seen in people who have plaque psoriasis or PsA.
  

Topical Treatments for Psoriasis

Topical treatments are applied directly to the skin or other affected tissues. Those for psoriasis come in different formulations—creams, gels, bath solutions, patches, foams, shampoos, and more. They are available in over-the-counter (OTC) and prescription strengths. 

Over-the-Counter Treatments

OTC topical treatments for psoriasis can be purchased without a prescription from your local pharmacy or supermarket, from online retailers, or directly from the manufacturer. Your healthcare provider can help you to decide which formulations might best treat your psoriasis. 

Two common active ingredients found in many topicals that treat psoriasis—coal tar and salicylic acid—have been approved by the Food and Drug Administration (FDA) for treating psoriasis.

Salicylic acid is a keratolytic (a peeling agent) that helps the outer layer of skin to shed better. For treating psoriasis, it softens and lifts skin scales. Long-term side effects of salicylic acid are skin irritation, weakening of hair shafts, and hair loss.

Coal tar can slow down the growth of skin cells and restore skin appearance. It might also help reduce skin swelling, itching, and scaling. Coal tar can irritate and dry skin. Using a moisturizer first and then applying the coal tar might reduce dryness. Coal tar can stain clothing, bed linens, and lighter color hair and increase your risk for sun sensitivity. 

Mild OTC corticosteroids (sometimes called steroids) are available in topical form and can help reduce inflammation and skin cell growth. Side effects might occur with long-term and improper use and include thinning skin, spider veins, stretch marks, and acne-like breakouts.

Prescription Treatments

Your healthcare provider might prescribe a more potent topical treatment if psoriasis covers large areas or your skin lesions are in harder-to-treat areas. Harder-to-treat areas include the knees and elbows, where the stratum corneum, the outermost skin layer, is much thicker.

Topical steroids are available in prescription strengths and are typically applied once or twice daily. Your healthcare provider might suggest you wrap treated skin areas to help the medicine work better. The side effects of topical prescription steroids include thinning skin, skin color changes, bruising, stretch marks, and broken blood vessels.

Vitamin D topicals are another prescription option for treating psoriasis. These treatments are safer than corticosteroids and just as effective, but they can irritate the skin. Your healthcare provider might recommend using vitamin D with a steroid because the combination treatment can be more effective. 

Additional prescription topicals available for treating psoriasis include:

• Retinoids: These can help shed skin cells.
• Anthralin: This eases inflammation and slows down skin cell growth.
• Elidel (pimecrolimus) and Protopic (tacrolimus): These calcineurin inhibitors in slow down the immune reaction to manage skin inflammation.
• Vtama (tapinarof): The first-ever aryl hydrocarbon receptor (AHR) agonist, it treats mild to moderate plaque psoriasis by modulating the immune response, helping the skin barrier return to normal, and having an antioxidant effect.
• Zoryve (roflumilast): This phosphodiesterase-4 (PDE4) inhibitor reduces inflammation and is approved for plaque and inverse psoriasis.
  

What Types of Psoriasis Are Topical Treatments Best For?

Plaque, guttate, and inverse psoriasis are treated with OTC and prescription topical steroids.

Pustular psoriasis is sometimes treated with topical medicines, although steroids can sometimes lead to pustular psoriasis outbreaks. Treatment for pustular psoriasis will depend on the extent of the outbreak and may include topical medicines to treat sores. 

Nail psoriasis is typically not treated with topical skin treatments. PsA can be treated with topical medicines if it causes skin symptoms, or your healthcare provider recommends a topical pain reliever for joint pain. 

Oral and Injected Medications

Psoriasis is an autoimmune disease stemming from internal processes. This means your skin may not be completely clear even with topical therapy.

Oral and injected therapies include drugs that affect the whole body. Your options for oral and injected medicines used for psoriasis are biologics, steroids, and oral medicines.

Biologics

Biologics that treat psoriasis and PsA block the action of specific inflammatory proteins that play a role in these conditions. Biologics are sometimes called disease-modifying antirheumatic drugs (DMARDs) because they slow down or stop the processes in the body that lead to damaging inflammation.

Biologics are given by injection or through intravenous (IV) infusions (delivered into a vein). Most biologics can be injected at home, but infusion treatments are typically done at your healthcare provider's office, an infusion center, or another healthcare facility.

Biologics can be pretty effective but can increase your risk of severe infections. They are typically used with other therapies, including topicals and light therapy. 

Biologics for treating psoriasis and PsA are:

• Tumor necrosis factor-alpha (TNF-alpha) inhibitors, including Cimzia (certolizumab pegol), Humira (adalimumab), Remicade (infliximab), and Simponi Aria (golimumab)
• Interleukin 12 and 23 (IL-12, IL-23) inhibitors, including Stelara (ustekinumab)
• Interleukin 17 (IL-17) inhibitors, including Cosentyx (secukinumab) and Taltz (ixekizumab)
• T-cell inhibitors, including Orencia (abatacept)
• Interleukin 23 (IL-23) inhibitors, including Skyrizi (risankizumab-rzaa) and Tremfya (guselkumab)
  

Steroids

Oral steroids help reduce inflammation and pain. Your healthcare provider might prescribe an oral corticosteroid to manage skin inflammation and offer pain relief from sore and tender skin. 

While oral steroids can help manage psoriasis flares, they are typically not prescribed to treat skin symptoms of psoriasis. This is because the discontinuation of steroids could lead to the development of pustular or erythrodermic psoriasis.

Oral steroids might be an option to manage flare-ups from PsA. However, they should be used with caution as they may adversely affect people who have skin involvement.

Long-term use of oral corticosteroids is linked to high blood pressure, diabetes, eye problems, osteoporosis (progressive bone thinning), and heart disease.   

Oral Medications

The most prescribed oral medicines for psoriasis are Soriatane (acitretin), methotrexate, and cyclosporine. 

Soriatane is the only oral retinoid available for treating severe adult psoriasis. Because it is known for causing severe side effects, it is often prescribed to treat psoriasis flares but not as an ongoing treatment. Side effects include hair loss, dry mouth, skin and lip chapping, aggressive thoughts and changes in mood, headaches and eye pain, joint pain, and liver damage.

Methotrexate inhibits enzymes involved in the rapid growth of skin cells. It is typically given to people who have not benefited from other treatments. Side effects include fatigue, nausea, stomachache, dizziness, headaches, and increased infection risk.

Cyclosporine is an immunosuppressive drug that causes the immune system to slow down the growth of skin cells. Side effects include headaches, fever, gastrointestinal problems, back pain, shortness of breath, fatigue, swelling and bruising, and increased blood pressure. 

Additional oral medicines used to treat psoriasis are:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation, joint pain, and stiffness
• Otezla (apremilast), which targets an enzyme known as phosphodiesterase 4 (PDE4) that controls inflammatory action between cells
• Xeljanz (tofacitinib) and Rinvoq (upadacitinib), which are Janus kinase (JAK) inhibitors that target a specific part of the immune system to reduce its overactive response, approved for treating psoriatic arthritis
• Sotyktu (deucravacitinib), which inhibits a tyrosine kinase 2 (TYK2) to calm down the immune system
  

Some healthcare providers may prescribe systemic medicines off-label to treat psoriasis. Off-label prescribing means the drug is being prescribed for another use other than the FDA-approved use. 

Off-label systemic drugs used to treat psoriasis include:

• Azulfidine (sulfasalazine)
• CellCept (mycophenolate mofetil)
• Hydrea (hydroxyurea) 
• Isotretinoin 
  
• Tabloid (6-thioguanine)
  

What Types of Psoriasis Are Oral Treatments Best For?

Most injected and oral treatments for psoriasis are prescribed to people with moderate to severe disease symptoms. Your healthcare provider will also prescribe them when other therapies have not worked for you or if you cannot use topicals.  

Moderate to severe plaque or guttate psoriasis is typically treated with cyclosporine and methotrexate, biologics, and oral retinoids.

People with inverse psoriasis might benefit from Otezla, cyclosporine and methotrexate, and biologics. Pustular psoriasis is typically treated with topicals, but healthcare providers might prescribe biologics to reduce or prevent recurrences.

Erythrodermic psoriasis is a medical emergency and requires hospital care. You will be treated with a combination of therapies, including topical steroids, medicated dressings, biologics, or oral prescription medicines until symptoms have improved.

Treatments for PsA include NSAIDs, oral corticosteroids to manage flares, and DMARDs, including methotrexate and biologics.

Nail psoriasis is treated with biologics and oral medicines, including methotrexate.

Phototherapy

Phototherapy, sometimes called light therapy, involves exposing skin to controlled amounts of ultraviolet (UV) radiation. Treatments need to be consistent and done under a healthcare provider's care. 

For treating psoriasis, phototherapy might help reduce inflammation and slow skin cell growth. It might also improve itch and pain. 

What Types of Psoriasis Does Phototherapy Treat?

Most people with psoriasis are prescribed a type of UV phototherapy called narrowband UVB that uses an excimer laser to manage skin symptoms. This laser can treat psoriasis on the ears, scalp, armpits, groin, buttocks, elbows, and knees for children and adults. 

According to the American Academy of Dermatology Association, phototherapy effectively treats plaque psoriasis, palmoplantar psoriasis, nail psoriasis, and scalp psoriasis. Side effects include a sunburn-like reaction, mild stinging, and itching. 

Choosing the Right Treatment for Psoriasis

Treating psoriasis can be exhausting and time-consuming. It also requires a willingness to try different treatments or a combination of therapies until you find the best approach to managing symptoms. 

Figuring out which treatments might best work for you will depend on your personal preferences, costs (including what your insurance plan covers), what treatments you have tried in the past, and your overall health. 

You should reach out to your healthcare provider anytime you experience skin pain, increased or new symptoms, or if treatments are not helping. They can change your treatment plan and get you back on track. 

Managing Psoriasis Flare-Ups

Psoriasis is a condition that waxes and wanes. You can experience disease flare-ups in which your skin is inflamed, sore, and covered in patches and scales. You will also experience times of remission where the skin is clearer, and itch and pain levels are low. 

Understanding Triggers

Flare-ups are sometimes the result of specific triggers. You may also experience a flare with no exact cause or trigger. 

Triggers of psoriasis flares will vary from person to person. Common triggers of psoriasis flares are diet, stress, alcohol, and smoking.

Diet

Research shows that diet plays a role in the severity of psoriasis. According to one study reported in 2018 in JAMA Dermatology, reducing calories if you are overweight could help improve psoriasis symptoms.

The National Psoriasis Foundation recommends eating healthful foods to manage symptoms of psoriasis and PsA and reduce the risk for comorbid (coexisting) conditions. Some foods are considered anti-inflammatory and might help reduce inflammation, so you have fewer flare-ups. 

Examples of anti-inflammatory foods are:

• Almonds
• Avocados 
• Berries (strawberries, blueberries, raspberries, and blackberries)
• Cherries
• Cruciferous vegetables (broccoli, cauliflower, kale, etc.) 
• Dark chocolate 
• Extra virgin olive oil
• Fatty fish (salmon, sardines, herring, mackerel, etc.)
• Green tea
• Mushrooms 
• Turmeric  

Stress

Stress is a known trigger of psoriasis flares. The research on psoriasis shows that stress is linked to disease onset and subsequent flares.

Psoriasis flares and visible symptoms of the condition might also lead to psychological discomfort. Managing stress might help you to prevent flares. 

If you find you are struggling to cope with the effects of psoriasis, talk to your healthcare provider. They can offer information about resources and support to help you manage the psychological effects of the condition.  

Alcohol and Smoking

Both alcohol and smoking contribute to the development and exacerbation of psoriasis. Alcohol consumption triggers inflammation and might also reduce the effectiveness of treatments or lead to severe side effects.

Smoking worsens symptoms, reduces treatment response, and increases your risk for comorbid conditions like high blood pressure and diabetes.

Quitting smoking and reducing your alcohol intake could improve disease symptoms. Talk to your healthcare provider if you need help quitting.

Summary

Psoriasis is an autoimmune disease that occurs because the immune system malfunctions and attacks healthy tissues. There is no cure for the condition, but it is treatable and manageable.

Treatment for psoriasis aims to stop skin cell growth and remove scales. Your options are topical medicines, oral systemic medicines, biologics, and light therapy. 

The type of treatment you and your healthcare provider decide on depends on your type of psoriasis, the severity of symptoms, your response to other treatments, and your overall health. You might need to try different therapies before finding what best works to manage symptoms and reduce flare-ups.