Let's Talk About Psoriasis Treatment
When it comes to treating the scaly skin disorder, you've got options—lots of them. So what's best for your specific type?by Krista Bennett DeMaio Health Writer
If you’ve been recently diagnosed with psoriasis, you’re probably wondering how to get rid of it—fast. We get it. Those unsightly red, scaly patches can itch, sting, and burn, and you just want to hide away until they’re gone. While there’s no cure for the chronic skin condition, there are plenty of ways to treat and control it. Finding the right regimen can get—and keep—your skin clear and calm again. Keep reading to learn how to get over the sting and stigma of your psoriasis.
Our Pro Panel
We went to some of the nation's top psoriasis experts to bring you the most scientific and up-to-date information possible.
Mark Lebwohl, M.D.
Chairman of the Kimberly and Eric J. Waldman Department of Dermatology
Icahn School of Medicine at Mt. Sinai
New York, NY
Lawrence Eichenfield, M.D.
Chief of Pediatric and Adolescent Dermatology, Professor of Dermatology and Pediatrics
Rady Children's Hospital and University of California, San Diego School of Medicine
San Diego, CA
Jeremy Fenton, M.D.
Medical Director for Schweiger Dermatology Group, Clinical Instructor
New York, NY
It’s best to talk to a doctor who focuses on and is well trained in all things skin-related, which is a dermatologist. Even better is a derm who specializes in psoriasis. He or she will know the ins and outs of this condition, treatment options, side effects, and more.
Unfortunately, there is no cure for this chronic condition. But the treatment options are extensive. With the help of your doctor and a little trial and error, you can find the one that helps you manage your psoriasis and live a full life with this disease.
There are some treatments—like certain biologics and oral medications—that work for both conditions. However, it’s best to consult a rheumatologist for your psoriatic arthritis since rheumatologists specialize in all types of arthritis.
Treat-to-target goals help patients and doctors gauge treatment effectiveness. The goal is for your psoriasis to cover 1% or less of your body in three months. If that’s not the case, you and your M.D. can reevaluate your plan.
What Is Psoriasis, Again?
Psoriasis is the skin equivalent of a massive traffic jam—only instead of cars, it’s skin cells that pile up and cause major irritation. When you have this skin disorder, your skin cells turn over at a way-faster-than-normal rate. All those cells cause a log jam on skin’s surface, forming red, scaly patches that can itch and/or sting.
Exactly why does this happen? Experts say it’s a combination of genetics, an overactive immune system, and at least one trigger such as infection, obesity, smoking, or skin injury.
There are several different types of the skin disorder. Many people associate psoriasis with sharply demarcated, red, scaly patches called plaques. But that’s a characteristic of just one type of psoriasis: plaque psoriasis (albeit, the most common one).
There are seven types in total, and which one you have will help determine which treatment you’ll end up with. Here, a rundown of the most prescribed treatment options for the different types of psoriasis.
Topical creams, ointments and lotions are applied directly to affected areas and are best for mild to moderate psoriasis that covers 1% to 10% of your body. Topicals are often used to treat:
This category includes topical corticosteroids, vitamin D analogues, retinoids and over-the-counter products with salicylic acid or coal tar and can come as creams, lotions, ointments or shampoos. Which one you use has to do with the size of the area you’re treating and the severity of your psoriasis, among other factors.
Salicylic acid products like Neutrogena T/Sal, Salicyn and Keralyt
Coal tar products
Vitamin D analogues and combo products:
Enstilar (calcipotriene and betamethasone dipropionate)
Taclonex (calcipotriene and betamethasone dipropionate)
Clobex (clobetasol propionate)
Clobex (clobetasol propionate)
Duobril (halobetasol propionate) and (tazarotene)
Off-label prescription topicals:
In tablet or capsule forms, oral medications work by homing in on your overactive immune system or parts of it to reduce inflammation and/or change how fast skin cells are produced. Oral medications are often used to treat:
Some oral meds can make you more susceptible to infection and/or negatively affect organs like your liver, kidney, and heart. And some work better for certain people but not others. With so many choices, your doctor can help you find the best oral option for you to take alone or combine with other forms of treatments like topicals, phototherapy, or biologics. Oral medications that are prescribed for psoriasis and/or psoriatic arthritis, include:
Xeljanz and Xeljanz XR (tofacitinib)
Just as with other psoriasis treatments, oral options can have side effects such as flu-like symptoms, high blood pressure, chapped lips, and nausea, among others, that vary from one oral medication to another and from person to person.
Light therapy, also known as phototherapy, is a tried-and-true option for mild to moderate psoriasis. It can also be combined with other treatments (like oral medications or topical products) for moderate to severe psoriasis. Light therapy is often used to treat:
During phototherapy, light is emitted from a device that’s either full-body-sized or smaller and targeted to a specific area like your feet or scalp. Doctors use ultraviolet A or B light to slow down the overgrowth of skin cells. Narrow-band ultraviolet B light (UVB) is the wavelength commonly used to get the best results. It also carries a lower risk of skin cancer than other wavelengths (though broad-band UVB and ultraviolet A, or UVA, are also available as treatments). Side effects include:
A potential risk of cold sores (if you have a history)
Sunburn (typically mild)
Phototherapy is typically done in your dermatologist’s office or another healthcare setting. Your physician can also shrink down lesions with the excimer laser, which also uses a concentrated dose of UVB light. It’s typically done twice or three times a week and takes up to 10 sessions for best results.
You can DIY your phototherapy with an at-home device prescribed by your doctor. There are full-body-sized at-home devices that look like household room dividers with a screen that you stand in front of. There are also hand-held devices that are aimed at specific body parts.
After protecting sensitive areas, such as covering your eyes with goggles, putting sunscreen on your lips or protecting your genitals with a small shield, you’ll need to use the light for 15 to 30 minutes, several times per week for at least two months to clear or improve skin. Maintenance treatments may be needed after that. (Home devices may be covered by insurance.)
Biologics, which are made from the cells of animals, humans, or bacteria, are commonly prescribed for moderate to severe psoriasis because they’re so effective. A biologic is usually given through an intravenous drip (IV) or injected into your thigh, upper arm, stomach, or buttock either by you or a health care provider. These are known as systemic treatments because they spread throughout the body and do their work from the inside (as opposed to topicals or light-based treatments that work on the outside). Biologics are often used to treat:
Once inside, biologics zone in on overactive immune system proteins or white blood cells (TNF-alpha, interleukin 17, interleukin 12, interleukin 23 and/or T-cells) that contribute to psoriasis. Because they play well with other treatments, biologics are often combined with phototherapy, topicals, and oral medications for even better results.
Of course, just like other drugs, biologics can have side effects, sometimes serious ones. For example, because they inhibit parts of your immune system, they can increase your risk of infections. As a result, they’re not recommended for those with compromised immune systems or those taking other immune-suppressing drugs. Biologics, which are prescribed for all types of psoriasis and/or psoriatic arthritis, include:
Cimzia (certolizumab pegol)
Simponi Aria (golimumab)
Each biologic is different, but some common side effects include:
Skin rash where the injection or IV is given
That said, biologics are believed to be safer for your organs than some oral medications.
While you can’t control your psoriasis through diet alone, some small studies and anecdotal evidence suggest that good nutrition may improve your symptoms. Some people with this condition may find that alcohol and spicy foods cause a psoriasis flareup or worsen an existing one.
In a study conducted by the University of California-San Francisco School of Medicine, more than 50% of the 1,200 people surveyed said that limiting their intake of nightshade veggies (tomatoes, eggplant, peppers and potatoes) helped ease their symptoms. The same study found benefits from consuming other veggies and popping fish oil and vitamin D supplements.
Shedding a few pounds may also help since body fat can cause inflammation. People who are overweight or obese can have more severe psoriasis and may not reap the same results from treatment as others.
Add psoriasis to the lengthy list of things that you can blame on stress. Experts say stress can lead to an inflammatory cascade that triggers the skin condition if you have the genetic predisposition. It’s also a catch-22 because stress can worsen or trigger your psoriasis, which just makes you more, well, stressed.
So, can you control your psoriasis if you control your stress? The research is limited, but there’s some evidence to suggest that combining stress reduction methods with traditional therapy may speed up results. And less stress may also mean fewer flare-ups in the future.
One small study has shown that meditation combined with phototherapy lead to faster clearing of psoriasis. A large-scale study in the Archives of Dermatology found that vigorous exercise (three to four hours a week) reduces the risk of psoriasis in women by 25% to 30%.
Getting the Right Treatment
You’ve probably noticed there’s a lot of overlap with treatments for different types of psoriasis. Your doctor will suggest the best one for you based on your type of psoriasis, but also these factors:
Location, Location, Location
Let’s say you have plaque psoriasis on your face. You may take an oral medication or biologic (a drug derived of living cells) because slathering your cheeks in greasy ointment may be unappealing to you.
If your scaly red patches are on your scalp, a medicated shampoo may be your best bet. Size matters, too. If the affected area is small, a topical product may be the solution, but a much larger area may be too big to cover in cream.
Mild to moderate psoriasis may respond to topicals while more severe cases might need biologics, light therapy, oral medications or a combination of these. What constitutes a mild case versus a severe one? Experts consider psoriasis:
mild if it covers less than 3% of your body
moderate if it covers between 3% and 10%
severe if it covers more than 10% of your skin
Your lifestyle and habits can also have an impact. For example, let’s say you have severe psoriasis on exposed areas like your arms, legs, and face that makes you self-conscious and your job requires public speaking. In this kind of case, using a topical product on an affected area might not be effective or cosmetically appealing and a biologic or oral treatment might be a better choice.
Your Health History
Some psoriasis drugs can bump up your blood sugar, so these won’t be prescribed if you have diabetes. Others can raise your blood pressure, so if this vital sign is already high, your doc will avoid it.
Or, if you’re currently taking medication for another condition that weakens your immune system, your M.D. won’t prescribe an immune-suppressing psoriasis treatment because it will further compromise this system and raise your risk of infections or other illness.
Pregnant or nursing? That would rule out several skin-soothing options such as methotrexate, which can be toxic, and Soriatane, which is a form of vitamin A so it can increase your risk of birth defects.
While trial and error play a role in finding the right treatment, if one doesn’t improve your psoriasis, it’s not necessarily time to move on to another. Instead, your doctor may adjust your dosage and/or frequency of treatment or combine it with another type.
For example, you may be prescribed an injectable biologic and an oral med or receive phototherapy. A review in the British Journal of Dermatology found that combining the drug methotrexate with a biologic led to better results than a biologic alone. Patience is key, too. In general, it takes three to four months to see an improvement.
Finding the right psoriasis treatment probably feels daunting. The good news is that there are tons of options out there, and new treatments are being developed all the time. If you're suffering from psoriasis and can't see the light at the end of the tunnel quite yet, know that we, and your psoriasis community, are with you through it all.
- Dermatologist Recommendations: American Academy of Dermatology (AAD). (n.d.). “Psoriasis Resource Center.” aad.org/public/diseases/scaly-skin/psoriasis
- OTC to Reduce Psoriasis Symptoms: National Psoriasis Foundation. (n.d.). “Over the Counter Products.” psoriasis.org/sites/default/files/otc_product_fact_sheet_1.pdf#utm_source=EduPageCP
- Combining Psoriasis Medications: British Journal of Dermatology. (2015). “Combining Biologics with Methotrexate in Psoriasis: A Systematic Review.” onlinelibrary.wiley.com/doi/abs/10.1111/bjd.13573
- Overview of Biologics: US National Library of Medicine National Institutes of Health. (2017). “Old and New Biological Therapies for Psoriasis.” ncbi.nlm.nih.gov/pmc/articles/PMC5713267/
- Educational Materials: National Psoriasis Foundation. (2018). “Topical Treatments.” psoriasis.org/sites/default/files/topicals_booklet_3.pdf?utm_source=EduPageCP
- Diet and Psoriasis: National Psoriasis Foundation. (2018). “Diet and psoriasis.” psoriasis.org/advance/national-survey-maps-influence-diet-psoriasis
- Meditation and Psoriasis: Psychosomatic Medicine. (1998). “Influence of Mindfulness Meditation-based Stress Reduction Intervention on Rates of Skin Clearing in Patients With Moderate to Severe Psoriasis Undergoing Phototherapy (UVB) and Photochemotherapy (PUVA).” ncbi.nlm.nih.gov/pubmed/9773769
- Exercise and Psoriasis: JAMA Dermatology. (2012). “The Association Between Physical Activity and the Risk of Incident.” Psoriasis.” jamanetwork.com/journals/jamadermatology/fullarticle/1158558
- Excimer Laser for the Treatment of Psoriasis: National Institutes of Health. (2016). “Excimer Laser.” ncbi.nlm.nih.gov/pmc/articles/PMC5683125/