Four roads to one destination – navigating psoriasis treatment options

Learn more about treatment options

There are many different treatment options to help manage and alleviate psoriasis symptoms. Your doctor can help to find the right treatment for you.

Typically, we divide the different treatments into four main categories.

  • Topical treatments: Include products that are applied to the surface of the skin such as creams, gels or ointments.5
  • Phototherapy: Either ultraviolet light or sunlight.5
  • Systemic treatments: Medicine taken orally or through injection.5 Systemic treatments affect the body as a whole and not just a local skin area.5
  • Biologics: These are a special type of systemic treatment – that usually target a specific part of the immune system.5

Topical treatments

Topical medications are treatments that are applied directly to the skin – typically a cream, gel or ointment. Normally your doctor will start up with a topical treatment if you suffer from mild to moderate psoriasis. 

Prescription topicals

The most commonly prescribed topical treatments for psoriasis indications contain either a corticosteroid or a D-vitamin derivative. Combinations of D-vitamin with corticosteroids are frequently used as well.

  • Topical corticosteroids: Topical steroids are synthesized from the natural corticosteroid hormones that are produced by the adrenal glands in the body.3 These topical corticosteroids may help reduce swelling, irritation, redness and itchiness in psoriasis patients.3 A variety of brands are available with different types and strengths of corticosteroids. The more potent the strength, the more careful you have to be with prolonged treatments. Common side effects include skin thinning, changes in pigmentation, easy bruising, stretch marks, redness and dilated surface blood vessels.3 Usually, strong corticosteroids should not be used daily for a long period of time. Please consult your physician before terminating any treatment.
  • Vitamin D3 analogues: Vitamin D3 analogues include the naturally occurring, calcitriol, or the synthetic form of vitamin D3 called calcipotriene . These topicals may help slow down the growth of skin cells, flatten lesions and remove scales.4 Common side effects are skin irritation, stinging and burning. For calcitriol there is also an increased sensitivity to sunlight.4
  • Combination of corticosteroid and vitamin D3 analogue: Combination drugs which contain both a corticosteroid and a vitamin D analogue are commonly prescribed for patients with psoriasis. This combination helps slow down the development of skin cells, flattens lesions, removes scales and reduces swelling, irritation, redness and itchiness.4 Side effects may include itching, rash, and a burning skin sensation.
  • Salicylic acid: This active ingredient is referred to as ‘keratolytic’ meaning that it dissolves or breaks down the outer layer of skin (the keratins). It is often used in combination with other treatments to help enhance their effectiveness. Keratolytic products can help soften the skin and remove scales.2 However, they can also cause skin irritation, especially if left on the skin for too long.
  • Coal tar: Shampoos and solutions that contain tar can help slow the rapid growth of skin cells, and reduce inflammation, itching and scaling.2 However, tar products can redden and irritate the skin, and they stain clothes, bed-linen and light-colored hair. Tar products also make the skin more sensitive to artificial or natural light, so it’s important to use sunscreen and be careful with sun exposure.2 In some cases, coal tar is used in combination with ultraviolet light B (f. ex Goekerman’s regimen).
  • Anthralin: The active ingredient is derived from the bark of Araroba tree, and has been used for more than a hundred years against psoriasis. It can reduce the rapid growth of skin cells in plaque psoriasis.4 It may however cause skin irritation and can stain hair and unaffected skin, clothing and bed linens.4 It can cause skin irritation if it comes in contact with healthy skin around the lesion and it is therefore usually only used in hospitals where a nurse can help apply it correctly.
  • Vitamin A derivative: Tazarotene is a retinoid, or vitamin A derivative, used topically to slow skin cell growth. Often times, the psoriasis plaques turn redder before they start clearing with this treatment. The redness may be intense, however, it is usually not painful. Common side effects include skin irritation, dry skin, and increased sensitivity to the sun.3
In addition to the topical treatments which are only available on prescription, a number of non-prescription topical products are available over the counter (OTC). You can buy OTC products in pharmacies, drugstores, or supermarkets. Both keratolytic and coal tar products in mild solutions can be found as OTC-products.

It is not exactly known how light therapy works, but it is known that natural light and specific forms of ultraviolet light treatments can substantially improve psoriasis.


Phototherapy

While sunburn can induce psoriasis flares, sunlight can have a positive effect on many patients with psoriasis.7
Treatments may thus include systematic exposure to sunlight or treatment with artificial ultraviolet light. Light therapy (sometimes called phototherapy) is used to treat moderate-to-severe psoriasis. 

There are 2 kinds of phototherapy:

  • Ultraviolet light B (UVB): This type of ultraviolet light is also present in normal sunlight. It penetrates the skin and helps slow down the growth of the affected skin cells. When treated with UVB light you are exposed to the light for a certain length of time and on a regular schedule.6
  • PUVA (Psoralen + Ultraviolet light A): Phototherapy can also be based on ultraviolet light A. This type of UV-light is only efficient when combined with the light-sensitizing drug psoralen. Psoralen enhances the effect of the light treatment and helps slow down excessive skin cell growth and reduce or clear psoriasis symptoms. Common short-term side effects of PUVA are nausea, itching and redness of the skin.6 Please consult your physician for more information on the potential risks associated with PUVA treatment.


Systemic treatments

Systemic treatments for psoriasis get this name because they affect the body as a whole and not just a local skin area.
  • Cyclosporine: This active ingredient works by suppressing the body’s immune response.9 This medication can provide rapid relief of psoriasis symptoms; however, it has a number of potential side effects.9 Cyclosporine is also known to have potential drug and food interactions9. Please consult your physician for more information on cyclosporine and its potential side effects.
  • Methotrexate: Methotrexate works by binding to and inhibiting an enzyme involved in the rapid growth of cells. It thereby slows the rate of skin cell growth. Methotrexate can potentially harm the liver; patients are normally instructed to limit or avoid alcohol.10 Blood tests are also required regularly with methotrexate treatment to ensure the drug is being processed safely by the body, including the liver, white blood cells, and bone marrow.10 Pregnancy should be avoided by either partner during treatment with methotrexate and to a certain time afterwards.10

Biologics

Biologic drugs, more commonly referred to as just “biologics”, are drugs that target specific parts of the immune system for psoriasis. Biologics are protein-based therapies that are primarily administered by an injection or as an intravenous infusion directly to the blood stream.11
Biologics are very expensive and typically prescribed for moderate to severe psoriasis. Please consult your physician to learn more about the side effects associated with biologic treatment for psoriasis. Always inform your doctor that you are on biologic treatment before receiving a vaccination.

Oral Treatment

  • Apremilast: This is an oral medication, approved in 2014, which is used to treat moderate to severe psoriatic arthritis. Apremilast works by inhibiting an enzyme known as phosphodiesterase 4 (PDE 4). PDE4 plays an active role in the inflammatory action within cells and therefore, inhibiting PDE4 can improve symptoms of redness and scaliness in people with psoriasis. The most common side effects, as observed in clinical trials, include diarrhea, nausea, and headache which usually lessen over time.12 Please consult your physician to learn more about the potential side effects associated with Apremilast.


[References]

  1. http://www.mayoclinic.com/health/psoriasis/DS00193/DSECTION=treatments-and-drugs, p. 1, Last accessed date: 11 Aug 2015 
  2. http://www.psoriasis.org/page.aspx?pid=411,p. 1. Last accessed date: 11 Aug 2015
  3. https://www.psoriasis.org/about-psoriasis/treatments/topicals/steroids, p. 1, Last accessed date: 11 Aug 2015
  4. http://www.psoriasis.org/about-psoriasis/treatments/topicals/non-steroid, p. 1, Last accessed date: 11 Aug 2015
  5. https://www.psoriasis.org/about-psoriasis/treatments, p. 1, Last accessed date: 11 Aug 2015
  6. https://www.psoriasis.org/about-psoriasis/treatments/phototherapy, p. 1 Last accessed date: 11 Aug 2015
  7. http://www.papaa.org/further-information/psoriasis-and-sun, p. 1, Last accessed date: 11 Aug 2015
  8. https://www.psoriasis.org/about-psoriasis/treatments/systemics, p. 1, Last accessed date: 11 Aug 2015
  9. http://www.psoriasis.org/about-psoriasis/treatments/systemics/cyclosporine, p. 1,Last accessed date 11 Apr 2015
  10. http://www.psoriasis.org/about-psoriasis/treatments/systemics/methotrexate, p. 1,Last accessed date 11 Aug 2015
  11. http://www.psoriasis.org/about-psoriasis/treatments/biologics, p. 1, Last accessed date: 11 Aug 2015
  12. http://www.otezla.com/otezla-prescribing-information.pdf, p. 1, Last accessed 11 Aug 2015 

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