Let's Talk About Psoriasis Medications

There’s no cure for psoriasis, but there are a lot of medications that can treat the chronic skin condition. Whether you’re newly diagnosed or still searching for the right treatment (yup, sometimes there’s a little trial and error), the number of choices can seem daunting. There are topicals, oral medications, and biologic drugs. While they all have the same overall goal—clear your skin—they do it in different ways. Some medications soothe and calm an outbreak, while others prevent future flares. The treatment plan you end up on is often determined by your type of psoriasis, its severity and location, and your overall healthy history. Here, we’ll walk you through all your options.

What’s Psoriasis, Again? Let’s Recap!

Psoriasis is a chronic condition that causes red, stinging patches or bumps on your arms, legs, and even your scalp. When you have this disease, your skin cells turn over faster than they should, leading to a buildup of cells on your body's surface that turn into those inflamed, scaly spots.

At first glance, it looks like a skin issue. And while that’s true, experts say it starts on a deeper level—in your immune system. An overactive immune system, along with a genetic predisposition for psoriasis, and at least one other factor such as infection, obesity, or smoking are thought to be the driving forces behind the condition.

So, What Are My Psoriasis Medication Options?

As we mentioned, there are several different types of psoriasis: plaque psoriasis (the most common type), scalp psoriasis, guttate, pustular, inverse, erythrodermic, and even psoriatic arthritis, which is a combo of psoriasis and arthritis. The medication you’re prescribed is often determined by your type, and may include topical treatments, drugs taken orally, and injections. Let's start by taking a look at topical medications for psoriasis.

Topical Treatments

These creams, ointments, foams, shampoos, and lotions are applied directly to the affected areas, and are often prescribed for mild to moderate cases—psoriasis that covers 1% to 10% of your body. Topical treatments can be used alone, or in combination with another treatment prescribed by your doctor. For example, you may use a cream along with an oral medication and/or light therapy. Topicals are used for these types of psoriasis:

• Plaque psoriasis
• Guttate psoriasis
• Scalp psoriasis
• Pustular psoriasis
• Nail psoriasis

The most common types of topical treatments prescribed for psoriasis include:

Corticosteroids

Corticosteroids work by reducing inflammation and redness. They’re often prescribed to clear a current flare but won’t necessarily stop your psoriasis from coming back in the future. There are various forms, including liquids, foams, and creams that come in various strengths. Examples include:

• Clobex (clobetasol propionate)
• Cutivate (fluticasone)
• Kenalog (triamcinolone)

Side effects include:

• Skin irritation at the application site
• Skin thinning (with long-term use)
• Stretch marks (with long-term use)
• Discoloration (with long-term use)

Vitamin D Analogues and Combo Products

These creams, liquids, and foams are believed to stop the overgrowth of skin cells, which may help prevent future psoriasis flares. They also help clear current patches by sloughing off scaly skin and flattening plaques so they are less noticeable.

• Dovonex (calcipotriene) is a synthetic form of vitamin D that comes in a cream or a liquid for scalp psoriasis. You apply it twice a day for up to eight weeks.

• Vectical (calcitriol) is a natural form of vitamin D that comes in an ointment formulation to use twice daily. While most topicals are okay to use during pregnancy, Vectical is not.

• Enstilar (calcipotriene and betamethasone dipropionate) is a foam that’s a combination of a synthetic form of vitamin D and a steroid. It’s approved for adults only and used once a day for up to a month.

• Taclonex (calcipotriene and betamethasone dipropionate) is a liquid vitamin D-steroid combo that’s approved for use in children ages 12 and up. Use it once a day for up to a month.

Research has shown that using a vitamin D analogue with a corticosteroid may not only be more effective than using either one alone, but the combo can even reduce the side effects that can come with strong steroid use. But side effects can include:

• Skin burning
• Itching
• Peeling

Topical Retinoids

Yes, the vitamin A derivatives that smooth wrinkles and clear acne can also help with psoriasis. Topical retinoids help alleviate redness, scaling, and inflammation, and regulate the high-speed skin-cell growth associated with the condition. Because of their risk of birth defects, retinoids should be avoided if you’re pregnant or planning to become pregnant.

• Tazorac (tazarotene), available as a gel or cream, is approved for adults and comes in two strengths. It is used once a day and can be applied daily for up to a year.

• Duobrii (halobetasol propionate and tazarotene) is one of the newest topical medications. This combo product contains a vitamin A derivative (called tazarotene) with an anti-inflammatory lotion. You use it daily as needed.

Side effects include:

• Redness
• Stinging
• Peeling
• Dryness
• Sun sensitivity

Anthralin

Anthralin is a man-made version of goa powder, a natural substance that comes from the araroba tree. Like many of the other topicals, this helps halt the excessive growth of skin cells and is approved for adults. It comes in a variety of formulations including a cream, ointment, and paste which can be used once a day on the skin. It also comes in a shampoo which can be used on the scalp. Anthralin-containing products include:

• Dritho-Scalp
• Drithocreme
• Psoriatec
• Zithranol
• Zithranol-RR

Side effects include:

• Skin redness
• Rash
• Animal studies have suggested that anthralin can cause tumors, but there’s no proven link between cancer and human use.

Oral Treatments

Taken by mouth, oral medications target your overactive immune system (or parts of it) to reduce inflammation and/or slow down skin cell production. With so many choices, your doctor can help you find the best oral option for you to take alone or in combination with other forms of treatment like topicals, phototherapy, or biologics. Oral medications are most often prescribed for the following psoriasis types:

• Plaque psoriasis
• Scalp psoriasis
• Inverse psoriasis
• Pustular psoriasis

The most commonly prescribed oral options include:

Anti-Rhuematics

Trexall and Rheumatrex (methotrexate) work by targeting and slowing the growth of skin cells. They come with a risk of toxicity, so they’re only taken once or twice a week, and not prescribed for long-term use. Methotrexate isn’t safe to take if you’re pregnant or nursing or have any blood issues like low white blood cell count or anemia.

Side effects include:

• Nausea
• Vomiting
• Dizziness
• Temporary hair loss
• Anemia
• Bone pain
• Kidney and liver problems

Immunosuppressants

Gengraf (cyclosporine) was initially used as a medication to ward off organ rejection. It works on severe psoriasis by slowing an overactive immune system. The drug is taken daily either in pill form or a liquid that you dilute in juice.

Side effects: Cyclosporine can cause decreased kidney function, flu-like symptoms, high blood pressure, and cholesterol. This is another medication that’s not safe while pregnant or nursing, and shouldn’t be taken for longer than a year. Avoid cyclosporine if you take anti-cancer, anti-fungal, anti-convulsants, or anti-inflammatory medications, as well as antibiotics, aspirin, or ibuprofen.

Janus Kinase (JAK) Inhibitor

Xeljanz (tofacitinib), one of the newer oral medications, inhibits a family of intracellular nonreceptors called Janus kinase, a.k.a. a JAK inhibitor. In doing so, it decreases cytokines, proteins that cause inflammation. By lowering inflammation in those with psoriasis, you get less symptoms.

Side effects include:

• Blood clots
• Bladder/urinary issues
• Blurred vision
• Body aches
• Chills
• Headache
• Diarrhea

Oral Retinoids

Soriatane (acitretin) is a form of vitamin A (a.k.a. a retinoid) that helps regulate those out-of-control skin cells. It’s taken orally daily. If you’re pregnant or planning to start a family within the next three years or have experienced sensitivity to retinoids in the past, this medication isn’t an option for you.

Side effects include:

• Eye issues such as dry eye and crusting of the lids
• Dry mouth
• Skin peeling
• Hair loss

Phosphodiesterase 4 (PDE4) Inhibitor

Otezla (apremilast) is one of the newest oral treatments. It works by reducing inflammation. Less inflammation may mean less outbreaks, or at least less severe ones. This can’t be taken with some other medications such as phenobarbital and rifampin.

Side effects include:

• Depression
• Weight loss

Systemic Steroids

Prednisone and Medrol (methylprednisone). Sometimes prescribed as pills or injections, these meds work by reducing inflammation and slowing cell growth. They help calm a flare-up but aren’t recommended for long-term use.

Side effects include:

• Low bone density and associated bone fractures
• Diabetes
• Heart disease
• High blood pressure

Biologic Injections

These drugs are commonly prescribed (alone or along with other meds) for moderate-to-severe psoriasis because they’re so effective—especially the newer kids on the block like Skyrizi, Cimzia, and Ilumya.

Biologics are known as “systemic” treatments because they spread throughout the body and do their work from the inside out, but unlike other drugs that affect your entire immune system, these zero in on very specific parts—various proteins or white blood cells that contribute to psoriasis such as tumor necrosis factor (TNF), interleukin 17, interleukin 23, and T-cells. By blocking these proteins and cells, the drugs can stop a psoriasis flare.

Interestingly, psoriasis biologics may help with other inflammatory issues such as heart disease. A recent study in JAMA Cardiology found that those who took biologics for psoriasis had a significant reduction in coronary inflammation, too.

Biologics are made from living cells of animals, humans, or bacteria and are given through an intravenous drip (IV) or injected in your thigh, upper arm, stomach, or butt either by a health care provider, caregiver, or yourself. (Don’t worry, your M.D. will make sure you know exactly how to do this before sending you off to self-inject.)

They’re used to treat these types of psoriasis:

• Plaque psoriasis
• Scalp psoriasis
• Inverse psoriasis
• Pustular psoriasis
• Nail psoriasis

There are several types of biologics:

Interleukin 23 (IL 23) Inhibitors

• Stelara (ustekinumab) is injected into your body to block a protein called IL-23 and IL-12. This helps ease the inflammation that can cause symptoms of both moderate to severe psoriasis and psoriatic arthritis. The drug requires two starter injections four weeks apart followed by four doses per year done 12 weeks apart.

• Ilumya (tidrakizumab-asmn) and Skyrizi (risankizumab-rzaa) require two initial doses, four weeks apart, to block the IL-23 protein. This is followed by four doses per year, every 12 weeks.

• Tremfya (guselkumab) also targets IL-23 with two starter doses four weeks apart and then every eight weeks.

Side effects are rare but include:

• Upper respiratory infections
• Fever
• Headache
• Fatigue
• Diarrhea
• Nausea

TNF Inhibitors

One cause of plaque psoriasis (which accounts for 80% of all psoriasis cases) is the excess production of a protein called tumor necrosis factor (TNF) which tells your skin cells to grow at an accelerated rate. These medications, which block TNF so that your skin cells grow more slowly, need to be taken over a long period of time to clear your skin.

Unlike some psoriasis medications, TNF inhibitors can be taken while pregnant or nursing (but of course, not without talking to your OB/GYN). However, you’ll want to avoid this category of biologics if you have multiple sclerosis (MS) or have an immediate relative with MS. Anti-TNF therapy has been associated with the demyelinating disease.

• Cimzia (certolizumab pegol) can either be injected by yourself or you can have it injected at your doctor’s offices with two doses the first time, then two doses two weeks later, followed by two doses two weeks after that. Following these initial shots, you have one every other week.

• Enbrel (etanercept) is unique because it is also approved for use in children. Although dosage can vary, you typically inject yourself with Enbrel twice a week for the first three months and then once a week for three months after that.

• Humira (adalimumab) starts with two doses on day one and continues with one dose every other week. Cyltezo and Amjevita are approved biosimilars to Humira.

• Remicade (infliximab) is given as an IV infusion that takes about two hours at your health care provider’s office. You begin with three starter doses administered during a six-week period, and then get one infusion every eight weeks. Inflectra and Renflexis are biosimilar.

Side effects are rare but include:

• Headaches
• Coughing
• Nausea
• Vomiting
• Stomach pain

IL 17 Inhibitors

These biologics contain a human antibody that blocks a protein called interleukin 17 (IL 17), which causes inflammation and an immune response. Before prescribing these biologics, your M.D. will make sure you don’t have latent tuberculosis, meaning you carry the tuberculosis bacteria but don’t have an active disease. IL 17 inhibitors can trigger a case.

• Cosentyx (secukinumab) is self-injected; two doses a week for four weeks and then once a month.

• Siliq (brodalumab) targets four of the IL-17 proteins (others target just one). You take one dose weekly for three weeks and then one dose every two weeks. (Siliq carries a warning about suicidal behavior and thoughts.

• Taltz (ixekizumab) is self-injected; two doses on the first day and then one injection every two weeks for three months. After that, you do it just once per month.

Side effects are rare but include:

• Runny nose
• Dizziness
• Wheezing
• Cough
• Fever
• Sore throat

T-Cell Inhibitors

These medications target T-cells, a type of white blood cell that causes inflammation.

Orencia (abatacept) is prescribed as a once-a-week shot for psoriatic arthritis, but it doesn’t help with skin psoriasis.

Side effects include:

• Cold-like symptoms
• Headache
• Nausea

Combining Biologics With Other Medications

In some cases, your physician may prescribe a biologic along with another medication such as a topical treatment or oral medication. Some people develop anti-drug antibodies (ADAs) to biologics, making them less effective after a while. A review in the British Journal of Dermatology found that combining a biologic with the systemic oral medication methotrexate may help prevent ADAs.