What We Know About Psoriasis Treatment

Psoriasis is one of the most common skin conditions that affects about 2% of the population. It is caused by a problem with the immune system that leads to inflamed skin and an overproduction of skin cells. While there is no known cure for psoriasis, several different treatment options are available to help keep this condition under control and improve the patient's quality of life by eliminating the troublesome symptoms of itch and the rash.

Treatment options

There are three basic types of treatment available to patients:

  1. Topicals - These treatments are available in different formulations, such as oils; creams: lotions; ointments; gels; foams; sprays, and shampoos.
  2. Phototherapy
  3. Systemics - The use of pills, injections, and intravenous (IV) infusions.

Psoriasis is a chronic condition with no known cure that, despite the best treatments, can come and go. Healthcare workers do their best to find a good regimen for each patient to keep symptoms under control.

If you are pregnant, thinking about becoming pregnant, or breastfeeding, some of the above treatment options may not be for you, since studies show certain medicinal combinations can lead to birth defects in your child. Talk to your dermatologist or primary health care provider before undergoing a treatment plan to ease your discomfort.

Basic skincare and a healthy lifestyle

As with any skin condition, good hygiene and a healthy lifestyle are basic components of a treatment plan to get any skin condition under control, including of course, psoriasis. Here are some recommendations:

  • Cleanse skin twice daily to remove dirt, oil, and bacteria. Use a gentle moisturizing cleanser, not bar soap.
  • Bathe with lukewarm water. Keep bathing time to 10-15 minutes.
  • Pat dry with a clean towel. Never rub your skin.
  • Moisturize your skin twice a day with thick cream or ointment. The proper moisturizer will draw in water (humectant) and then lock it in place with a protective barrier (occlusive). Humectants include hyaluronic acid and glycerin. Occlusives include petroleum and mineral oil. Moisturizers with aloe or colloidal oatmeal can help calm and soothe the skin.
  • Avoid psoriasis triggers, such as dry or cold weather, smoking; excess alcohol; stress; tattoos; infections; sunburns, and skin injury.
  • Stick to a healthy diet rich in antioxidant fruits and vegetables. Avoid high fat and high carb diets. Maintain a good weight. Patients with psoriasis are at increased risk for heart disease and diabetes.
  • Exercise and stay fit.
  • Avoid scratching or picking at your skin. Shave carefully.

Topicals options

Topical treatments are usually the first-line therapy for mild-moderate psoriasis and can be used alone or in combination with each other. Topicals can also be combined with phototherapy and systemic therapy for moderate-severe cases. Please consider using the following topical treatments:

  • Steroids - Steroids work by decreasing inflammation and slowing down the production of skin cells. They are available in different strengths: low, mid, and high potencies. Low potency steroids work best on delicate areas like the face, skin folds, and groin. However, long-term use of any strength of steroids can lead to thinning of the skin.
  • Vitamin D analogs - Vitamin D analogs (calcipotriene, calcitriol) decrease skin cell production. They are used alone or in combination with topical steroids. They can cause some irritation, but do not thin the skin as topical steroids do.
  • Calcineurin inhibitors - Calcineurin inhibitors (tacrolimus, pimecrolimus) decrease the inflammation in the skin. Unlike steroids, they do not thin the skin, and they are safe to use in sensitive areas. Some people experience transient irritation from these inhibitors that usually resolves after a week.
  • Retinoids - Topical retinoids (tazarotene) improve psoriasis by decreasing cell production. They may cause irritation, burning, and sensitivity to light.
  • Salicylic acid - Salicylic acid also decrease cell production to eliminate scaling, but may cause irritation for some patients.
  • Coal tar - Coal tar reduces inflammation and scaling. Some patients may experience irritation from using it. Many dislike coal tar because it has a strong odor and can stain clothing. It is often used with UVB light treatments to enhance results.

Light therapy

Light therapy, also known as phototherapy, is often used as a first-line treatment for moderate to severe cases of psoriasis. It utilizes light in particular wavelengths to slow down skin cell production and decrease inflammation. Light therapy can be used alone or in conjunction with topicals. It is safe for use during pregnancy and breastfeeding.

  • Sunlight - Sunlight may be beneficial in some cases of psoriasis. Patients are exposed to a short, controlled amount of sunlight daily. It is probably one of the oldest treatments for psoriasis. Be aware that cumulative sun exposure (can lead?) leads to skin cancers.
  • UVB broadband - This treats psoriasis with UVB light in the range of 280-320nm, and is not as effective as narrowband. Side effects include itching, redness, and dryness of the skin.
  • UVB narrowband - This is a newer treatment that uses UVB light at a specific wavelength of only 311nm. It is more effective for psoriasis, but has more side effects. Patients may experience itching, redness, dryness, and burns.
  • PUVA - During PUVA, patients take by mouth, or apply a light-sensitizing medication (to the affect area) before exposure to UVA light. This treatment is more aggressive, but also more effective to combat resistant cases. Since UVA penetrates deeper than UVB, there is an increased risk of skin cancers. PUVA can also cause headaches, nausea, skin burns, and irritation.
  • Excimer laser - This laser uses UVB light at 308nm to target small areas of psoriasis. Keep in mind that with this treatment there is a chance for skin burns and blistering.

Systemic therapy

Systemic therapy can be the first-line treatment for severe cases of psoriasis. They are very effective at treating psoriasis. However, these treatments are reserved for severe cases because they have potentially serious side effects, including infections and cancers. They are available in pills, self-administered injections, or IV infusions.

  • Steroids - Steroids reduce the inflammation and overproduction of skin cells. It can be administered as IM (intramuscular) injections or pills. Oral steroids have fallen out of favor due to the possibility of rebound worsening of psoriasis. However, small targeted IL (intralesional) injections can be helpful in some cases. When injections are delivered directly into small lesions (intralesional), there is less chance of systemic absorption and rebound worsening.
  • Retinoids - Systemic retinoids (acitretin) effectively reduce the overproduction of skin cells. They have significant side effects, such as severe dry skin, hair loss, and liver and blood problems.
  • Immunosuppressants - This group includes medications like methotrexate, cyclosporin, and hydroxyurea. They suppress the immune system to reduce inflammation and stop the overproduction of skin cells. The use of these medications requires frequent physician visits and laboratory monitoring. Methotrexate can alter blood counts, and cause liver failure, nausea, and fatigue. Cyclosporin can elevate blood pressure and cause kidney problems. The use of hydroxyurea may lead to bone marrow suppression.
  • Biologics - These medications effectively target specific types of cells that cause inflammation. They include Enbrel, Humira, Remicade, Otezla, Stelara, Cosentyx, Talz, and others. New medicines are entering the market frequently as research into the pathogenesis of psoriasis advances, but because these interfere with the immune system, some have serious side effects, like infections and cancers. They are also very expensive and may not be covered by many insurance plans.

Key take-aways

Psoriasis is a challenging skin condition to treat.

The goal of psoriasis treatment is to decrease the inflammation and eliminate the rash with as few side effects as possible.

There are many treatments available for psoriasis, like topicals, light therapy, and systemic medications.

It is vital to find a dermatologist that specializes in psoriasis and stick to the treatment plan.

References

American Academy of Dermatology (www.aad.org). Psoriasis.

Armstrong, April W, and Charlotte Read. “Pathophysiology, Clinical Presentation, and Treatment of Psoriasis: A Review.” JAMA. 2020; 323(19): 1945-1960.

Bakshi, Harman et al. “Treatment of Psoriasis: A Comprehensive Review of Entire Therapies.” Current drug safety. 2020; 15(2): 82-104.

Bolognia, J, Jorizzo JL, Schaffer, JV. (2012). Dermatology. Philadelphia: Elsevier Saunders.

Tokuyama, Michio, and Tomotaka Mabuchi. “New Treatment Addressing the Pathogenesis of Psoriasis.” International journal of molecular sciences. 2020;21(20):7488.

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