Lawrence Green, Washington, D.C., area dermatologist and Chair of the Research Committee for the National Psoriasis Foundation, answers questions about the various treatment options for psoriasis patients.
What are the treatment options for psoriasis?
Options for patients with psoriasis include topical or systemic treatments (such as pills, injections and light therapy). These treatments are administered based on how severe the patient’s psoriasis is. Topical treatments, usually in the form of ointments (but they can also be sprays or foams), are typically administered for patients whose psoriasis covers less than 5 percent of their body. Cortisone ointments are applied directly to the skin and are aimed at reducing skin inflammation where they are applied.
If a patient has psoriasis on more than 5 to 8 percent of his or her body’s surface, dermatologists usually prefer to use systemic treatments because it is difficult to apply topical ointments onto each spot every day. In this case, a dermatologist may opt to use a narrow band ultraviolet B light (NB-UVB), which can be applied all over the body to reduce the psoriasis. This may be challenging for some people, however, because the treatments have to be administered at least twice a week for a few months, and it is best performed in a dermatologist’s office.
Other systemic treatments commonly used are called “biologics.” Biologics are medications that are given in the form of an “injectable”—a medication injected subcutaneously. This type of treatment is administered, at most, once a week.
Finally, an older and now less commonly used systemic treatment for widespread psoriasis involves low doses of the oral chemotherapy medication methotrexate.
What does it mean when a treatment is referred to as “systemic”?
“Systemic” refers to a treatment that can affect more than just the areas of psoriasis you are aiming to treat. For example, if a dermatologist applies a topical steroid to treat one or a few areas of skin psoriasis, they are treating the psoriasis locally, not systemically. But, if they apply topical steroids on psoriasis plaques over a large part of your body, the treatment now becomes systemic, because so much of the topical medication is being applied to the skin. In this case it can be absorbed “systemically,” not just in the skin, but also throughout the body. (Note: It is not recommended to use topical steroids in this manner because it can affect the normal function of the body.)
Ultraviolet light therapy, biologics and oral medications, such as methotrexate, are all systemic treatments because they go through the entire body, not just the skin where you have psoriasis.
Are treatments ever used in combination? Why or why not?
Treatments can certainly be used in combination if the situation calls for it. Dermatologists always prefer to use one medication rather than two if we can, since it’s easier for the person being treated and, in general, one treatment is safer than two. However, sometimes patients will need a little boost to get their psoriasis improved, so a small dose of a second medication can be temporarily used. For instance, Dr. Erin Boh from Tulane University Health Sciences Center notes that if a patient is on a systemic medication, whether it’s an injectable or a pill by mouth, and isn’t getting a very good response, he or she is sometimes given light therapy as well.
What are the risks or side effects associated with each class of treatments?
If overuse occurs, topical cortisone preparations can cause thinning and lightening of the skin where they are applied. Cortisone injections can cause the same side effects. With laser treatments, the patient may be at risk for burns and tanned spots of the skin. Sun damage and skin cancer are risks with other types of phototherapy, such as NB-UVB or UVA light therapy (PUVA). Biologic medications and other systemic therapies, such as methotrexate, suppress certain parts of the immune system so someone who uses them could be at a slightly increased risk for certain types of infections or possibly some types of cancers.
How long do treatments last?
Unfortunately, there is no cure for psoriasis. We can only control and manage it. That said, topical treatments typically are used for four weeks or fewer if the psoriasis disappears sooner, and are then resumed when and if the psoriasis reappears. Phototherapy works the same way - it’s used for a few months until the psoriasis gets better and is resumed when it recurs. However, if someone has psoriasis that doesn’t go away easily or it recurs quickly after light therapy, they would probably benefit from a long-term systemic therapy, like a biologic, that has to be taken regularly to keep the psoriasis in check.
On average, how long does it take for someone to see improvement in their psoriasis with each treatment option and how often do treatments need to be administered?
With topical treatments, because there are fewer places to treat, patients typically see improvement in a few weeks. Systemic treatments, including phototherapy, biologics and oral medications, usually show improvement in a few months.
As for frequency of treatment, topical treatments are usually applied once or twice a day, narrowband UVB therapy is administered two to three times per week, the oral medication methotrexate is taken once a week, and biologics are injected subcutaneously anywhere from once a week to once a quarter, depending on the biologic being used.
Is treatment resistance a problem for many patients? What do you do in this case?
In general, based on the patient’s psoriasis severity, the dermatologist will recommend a treatment with which the patient should see some improvement. Unfortunately, with psoriasis and the complexity of the condition, there isn’t one treatment that everyone responds to perfectly. Luckily, there are many choices of treatment that can be used so if one is ineffective another can be used.
How much do each of these treatments cost? What resources are available if the patient can’t afford them?
Treatment costs can range anywhere from a few dollars to over $30,000 per year. If insurance doesn’t cover your treatment choice, often the treatment’s manufacturer has a program to help you receive them.
Are there natural and over-the-counter treatments I can do at home?
For patients with small amounts of psoriasis (less than 5 percent of their body covered), there are over-the-counter (OTC) coal tar preparations available. Other OTC treatments include products containing salicylic acid, hydrocortisone, camphor or menthol. It’s also important to keep psoriasis well moisturized with a heavy, fragrance-free moisturizer like petrolatum or Aquaphor. This will help reduce the scaling.