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What are the treatment options for mild and severe psoriasis?

Updated: May 19, 2023



 

Disclaimer: The information in this article is not meant as specific individual medical advice. Please consult your dermatologist or other medical professional about your skin or medical condition.

 

What is psoriasis?


Psoriasis is a chronic skin disease where people develop red spots and patches with thick white to silvery scale on their skin.


These patches may sometimes be itching or painful, although most of the time they are not.


The common parts of the skin affected by psoriasis are the scalp, face, elbows, knees, belly-button area (umbilicus) and the skin between the buttocks (gluteal cleft).


Psoriasis can sometime be widespread affecting large areas of a person’s skin.


About 1-in-5 people with psoriasis can develop joint pain, swelling and deformation. This is called psoriatic arthritis.


Psoriasis may begin at any age, and once it begins, it tends to continue for the rest of life.



What causes psoriasis?


Psoriasis is considered an autoimmune condition because it is a person’s immune system that is causing inflammation in the skin.


In psoriasis, white blood cells which are part of the body’s immune system is reacting to a person’s skin and causing inflammation (redness) and the skin cells to proliferate (reproduce faster).


This process causes the red scaly thick patches (also called plaques) that are typically seen on a person with psoriasis.


Unfortunately, this autoimmune process, once it begins, tends to continue through the rest of a person’s life.


There are genetic factors that determine if a person develops psoriasis, because psoriasis can run in families.


Psoriasis is not contagious and cannot spread from one person to another by touch or other contact.



What makes psoriasis worse?


There are lifestyle and environmental factors that can trigger or aggravate psoriasis.


These triggers include:

  • Skin injury, such as a sunburn or cut

  • Strep throat infection

  • Emotional stress

  • Medications such as lithium, prednisone and certain blood pressure medications called beta-blockers

  • Smoking

  • Heavy alcohol consumption



Types of psoriasis


There are a few distinct patterns of psoriasis.


These are:

  • Chronic plaque psoriasis

  • Guttate psoriasis

  • Palmoplantar psoriasis.



Chronic plaque psoriasis


Chronic plaque psoriasis is characterized by large red scaly plaques on the skin.


These plaques usually form on the scalp, face, elbows, knees, umbilicus and gluteal cleft.


It may sometimes affect the genital skin.


When it severe, it can cover 50 to 60% of a person’s body surface area.



Guttate psoriasis


Guttate psoriasis is characterized by small raindrop-like red scaly spots.


When it develops, it typically affects every part of a person’s skin.


This form of psoriasis is most commonly associated with or triggered by a Strep throat infection.


This is a common form of psoriasis in children.


In children, guttate psoriasis may sometimes resolve after a Strep throat infection has been treated.


Hence, it is important to look for Strep throat infection in a person who recently developed guttate psoriasis.



Palmoplantar psoriasis


This pattern of psoriasis typically causes red thick scaly plaques on a person’s palms and soles.


In addition, these plaques tend to be painful, which affects the normal use of a person’s hands and feet including activities like walking or running.



Psoriatic arthritis


Psoriatic arthritis is inflammation of the joints. This causes the joints to be swollen, stiff and painful.


With more joint damage over time, joints can gradually become deformed and people may lose function of the affected joints permanently.


While psoriatic arthritis usually develops in people who have skin lesions of psoriasis, it may sometimes develop without skin disease which makes it difficult to diagnose.


If you think you have psoriatic arthritis, it is helpful to consult with a rheumatologist, who is a medical specialist who specializes in treating this condition.



How is psoriasis diagnosed?


Psoriasis is usually diagnosed by a dermatologist from the typical skin lesions seen on a physical exam.


Occasionally, a skin biopsy may be performed to confirm if a skin disease is caused by psoriasis, especially when the typical skin findings are not seen.



Treatment options for psoriasis


There are numerous treatment options for psoriasis.


These can be generally classified as

  • Topical medications that are applied to the skin

  • Phototherapy

  • Systemic treatments that are oral medications or injected treatments



Topical treatments for mild psoriasis


Topical treatments are usually used for people with mild psoriasis.


They work by reducing inflammation in the skin.


They may not be strong enough to treat people with severe skin inflammation.


These treatments have the benefit of having minimal internal side effects compared with the other treatment options.


However, because it requires regularly twice daily application, it can be sometimes difficult for people to use it consistently enough to experience its full therapeutic effect.


It is also not practical for people with widespread areas of psoriasis to use topical treatments as the medications tend to be manufactured in small portions.


The most common topical treatments used in psoriasis are:

  • Topical corticosteroids (steroids)

  • Topical vitamin D analogs (calcipotriene, calcitriol)

  • Topical tazarotene (Tazorac®)

  • Topical calcineurin inhibitors (tacrolimus, pimecrolimus)

  • Tar



Topical corticosteroids ('steroids')


Topical steroids are usually the first-line of treatment for people with mild psoriasis.


Many people have misconceptions of what corticosteroids are.


Corticosteroids are naturally produced within our body as a hormone called cortisol.


Topical steroids are cortisol-based treatments that reduce inflammation when applied directly on the skin.


These are typically applied to the areas affected by psoriasis twice a day for two to four weeks, then as needed after that when a person’s skin is broken out.


Topical steroids are available as a wide variety of ingredients, each with a different strength and concentration, ranging from mild to very strong (ultrapotent).


Naturally, the strong the steroid ingredient, and the higher the concentration, the more effective it is.


Some examples of mild topical steroids are hydrocortisone and desonide.


Hydrocortisone 1% cream is sold over-the-counter in the United States, and is available at 2.5% strength as a prescription.


Mild topical steroids are usually used for the facial and skin fold areas where the skin is naturally thin.


Commonly prescribed medium strength topical steroids include triamcinolone and mometasone.


The stronger topical steroids are clobetasol, halobetasol and betamethasone diproprionate.


Medium and strong topical steroids are used to treat thicker plaques that are on the body and extremities.


Using medium and strong topical steroids on the face can also cause acne or rosacea to break out.


While long term use of topical steroids on normal skin can cause skin thinning, stretch marks, and visible blood vessels (called telangiectasia), this rarely occurs in psoriasis plaques.


The internal side effects associated with oral steroid use are rarely reported from topical steroid use unless large quantities are used over the long term.


If large quantities of topical steroids are used on large body areas for the long term, then it may lead to suppression of the body’s own ability to produce steroid hormones (also known as adrenal suppression).



Topical vitamin D analogs (calcipotriene, calcitriol)


These topical vitamin D treatments are derived from vitamin D and hence their name.


They are not the same as taking oral vitamin D supplements.


It appears that these topical vitamin D treatments decreases the growth rate of skin cells.


There are two topical vitamin D treatments available in the United States.


Calcipotriene is the more commonly prescribed treatment.


Calcipotriol is mostly available in Europe but is recently also available in the United States.


The effectiveness of these topical vitamin D treatments is about similar to a medium to strong topical steroid.


As topical vitamin D analogs do not cause skin thinning, these treatments may be safely used on the face, genitals and skin folds.


This is the main benefit that topical vitamin D analogs have over topical steroids.


Topical vitamin D treatments may occasionally cause skin irritation, but otherwise is associated with minimal side effect.


If used in large quantities in an unsupervised manner, it can increase blood calcium levels, although this side effect also rarely occurs.



Combined used of topical steroids with topical vitamin D analog


The combined used of a topical steroid with a topical vitamin D appears to increase the effectiveness of both treatments.


As such, both topical steroids and vitamin D analogs are often prescribed together.


Usually both treatments are used together twice a day for about 2 weeks.


Subsequently, the vitamin D analog are usually used on weekdays while the topical steroids are used on weekends.


There does not appear to be an increase in risk of side effects from their combined used.



Topical tazarotene (Tazorac®)


Topical retinoid, specifically tazarotene (Tazorac®), has been tested for use in people with psoriasis.


Retinoids are derived from vitamin A, and usually used to treat acne. You can read more about retinoid use in acne here.


Tazarotene has been tested in a clinical trial and shown to be safe and effective in reducing the severity of psoriasis when used over a 3-month period.[1]


It is meant to be applied once a day.


The main side effect is it may cause skin irritation when applied.


Hence, tazarotene is often used in combination with a topical steroid to reduce skin irritation.


Tazarotene use is not recommended to be used during pregnancy due to potential risk of birth defects.



Topical calcineurin inhibitors (tacrolimus, pimecrolimus)


Topical tacrolimus (Protopic®) and pimecrolimus (Elidel®) belong to a class of medication called calcineurin inhibitors.


In the United States, these treatments are FDA approved as a treatment for eczema or atopic dermatitis, and that’s their primary use. You can read more about tacrolimus and pimecrolimus in treatment of eczema here.


Tacrolimus[2] and pimecrolimus[3] are found to be effective in the treatment of psoriasis as well.


The main benefit of using these two treatments is they do not cause skin thinning when compared to topical steroids.


This means they can be safely used in areas where the skin is naturally thin, such as the face or skin fold areas.


In the United States, there is an FDA black box warning about these these two treatments and cancer including lymphoma when used in eczema or atopic dermatitis.


However, studies on the relationship of topical calcineurin inhibitors and cancer has not showed that these topical treatments cause cancer or lymphoma.[4] For more information, please refer to the article referenced in the footnotes.



Tar


Topical tar treatment has been used for years for the treatment of scalp psoriasis.


It appears to reduce inflammation and skin overgrowth in psoriasis.


Tar treatments are sold over-the-counter in the United States and are available as shampoo products, creams, lotions, ointments and oils.


These treatments are usually used once a day.


To maximize its effectiveness in the scalp, the tar treatment must come into contact with the scalp.


Ideally, it should be left on the scalp for 5 to 10 minutes before washing out.


One messy side effect of using tar is that it can stain the hair, skin and clothing.


It may also have a strong odor.



Treatment options for moderate to severe psoriasis


When psoriasis is severe, does not respond to topical treatments, or if topical treatments are not feasible due to the widespread areas of skin involved, then other treatment options have to be considered.


These treatments include:

  • Phototherapy including excimer laser

  • Methotrexate

  • Acitretin (Soriatane®)

  • Cyclosporin

  • Apremilast (Otezla®)

  • Biologic agents



Phototherapy


Ultraviolet (UV) radiation has long been used for treatment of psoriasis.


It appears to both reduce inflammation in psoriasis as well as decrease the rate of skin overgrowth.


Phototherapy using narrowband UVB is usually conducted in a dermatologist’s office two to three times a week continuously for at least a few months.


During treatment, a person stands in a booth surrounded by bulbs that emit narrowband UVB.


The treatment typically lasts up to a few minutes.


Phototherapy is especially effective in people with guttate psoriasis, compared to other types of psoriasis.


Phototherapy treatments can increase skin dryness, and topical moisturizer use is recommended.


While there are no major internal side effects, UVB phototherapy can accelerate skin aging and increase the risk of developing skin cancers. To learn more about skin cancer and their treatment, please read this.



Home-based phototherapy has become an alternative for people who are do not live close enough to their dermatologist’s office or whose personal schedules make it difficult for in-office treatments.


Home phototherapy units are available for sale and units cost about $3000 at the time of writing.


The risk of home-based phototherapy is the lack of supervision by a medical professional and the potential for unsafe or excessive use.


Some people use commercial tanning beds, however, there is enough variability of the UV radiation output of tanning beds that it is difficult to ensure safe usage.



Excimer laser


Excimer laser is a laser the emits UVB as well.


It is used to treat focal areas of skin affected by psoriasis, and is best used for people with limited or small persistent spots.


Excimer laser use can cause darkening of the treated skin (hyperpigmentation) like tanning. This slowly resolves after treatment is completed.



Methotrexate


Methotrexate is a commonly used oral prescription to treat moderate to severe psoriasis.


It reduces inflammation in psoriasis by suppressing the immune system broadly.


Methotrexate is taken once a week in combination with daily supplement of folic acid. Folic acid reduces the risk of developing side effects from methotrexate.


Methotrexate takes time to work. It takes a gradual increase of the dosage of treatment over a few months before improvement in psoriasis is seen.


The common side effects of methotrexate are stomach upset, headache and feeling tired (fatigue).


Methotrexate can also cause liver toxicity, liver cirrhosis and suppress a person’s bone marrow function (which produces blood cells).


As such, people taking methotrexate require lab testing to monitor blood counts and liver function.


Certain medications such as NSAIDS (e.g. ibuprofen) and certain antibiotics can increase the risk of side effects from methotrexate.


Methotrexate can cause severe birth defects if used during pregnancy and should not be used during pregnancy. For safety, it is recommended that methotrexate be discontinued 3 months prior to trying to get pregnant in both men and women.



Acitretin (Soriatane®)


Acitretin, like tazarotene (above), is a retinoid.


Acitretin is an oral version of a retinoid, which is also derived from vitamin A.


Acitretin is often used in combination with UVB phototherapy because it increases the effectiveness of phototherapy treatment and appears to reduce the amount of phototherapy needed to control psoriasis.[5]


However, acitretin is slow to work and it may take 3 to 6 months to see results.


Acitretin is used as a once daily oral medication.


Acitretin can cause severe birth defects during pregnancy, and pregnancy is not recommended until three years after stopping the medication.


In addition, acitretin use can cause skin dryness, raised blood fat (triglyceride) levels and liver toxicity.


As such, regular lab tests are usually performed to monitor a person’s lipid levels and liver function.



Cyclosporin


Cyclosporin is effective in treatment of moderate to severe psoriasis.[6]


It is an oral medication that is prescribe twice to three times a day, according to a person’s body weight.


Cyclosporin broadly and strongly suppresses a person’s immune system, and so reduces inflammation in psoriasis.


It has a rapid onset of action, and results can be noticed fairly quickly after starting cyclosporin.


However, due to its strong immune system suppressing effects, there is an increased risk of developing infections, including severe ones.


Cyclosporin may also cause kidney toxicity and high blood pressure, and suppress blood cell production.


As such, people taking cyclosporin can expect to have their blood pressure, blood counts and kidney function monitored regularly.



Apremilast (Otezla®)


Apremilast (Otezla®) is another oral medication that is used to treat moderate to severe psoriasis.[7]


It blocks a specific part of the immune system, called PDE 4, and reduces inflammation in psoriasis.


In clinical trials, about 30% of patients who used apremilast for 4 months experienced about a 75% improvement in their psoriasis.


When apremilast is started, it is usually prescribed in a gradual increasing dose over a 1-week period, until the dose of 30mg twice a day is reached.


This reduces the side effect of diarrhea, which can happen in 1-in-5 people who start taking apremilast.


Apremilast may also increase the risk of weight loss and depression.


Hence, it is important to monitor for mood and body weight changes when taking apremilast.



Biologic agents


There is currently a long and growing list of biologic agents that have been FDA approved in the United States to treat moderate to severe psoriasis.


Biologic agents target a specific part of a person’s immune system that is involved in causing inflammation in psoriasis.


These biologic agents do not cure psoriasis, and long-term use is required to maintain control of psoriasis.


Because these treatments block a part of the immune system, people who use these treatments are at a higher risk of develop infections, including severe ones.


There are currently three different classes of biologic agents depending which part of the immune system the treatment targets.


The three classes are TNF alpha inhibitors, IL-17 inhibitors and IL-23 inhibitors.


TNF, IL-17 and IL-23 are the parts of the immune system that a biologic agent targets.



TNF alpha inhibitors


TNF alpha inhibitors were the first class of biologic agents available to treat psoriasis.


These agents include

  • Etanercept (Enbrel®)

  • Adalimumab (Humira®)

  • Infliximab (Remicade®)

  • Certolizumab (Cimzia®)


Besides an increased risk of infection, TNF alpha inhibitors have the potential of reactivating infections such as hepatitis B and tuberculosis if a person has previously contracted them.


There appears to also be an increased risk of cancer in people who use TNF alpha inhibitors.



In the United States, etanercept (Enbrel®) is the first FDA approved biologic agent for use in adults and children four years and older with moderate to severe psoriasis.


The standard dose for etanercept in adults is an injection of 50mg twice a week for the first three months, followed by 50mg once a week for maintenance.


In clinical trials, up to 60% of patients on etanercept experienced a 75% improvement in psoriasis.



Adalimumab (Humira®) is an antibody that block TNF alpha.


Its standard dose is an initial injection of 80mg, then another injection of 40mg after a week, followed by 40mg every two weeks.


In clinical trials, up to 80% of patients on adalimumab experienced a 75% improvement in psoriasis.



Infliximab (Remicade®) is a TNF alpha inhibitor that is administered as an intravenous infusion.


The standard dosing is an infusion at week 0, 2, and 6, followed by every 8 weeks after that.


It has the benefit of having a faster onset of action.


In clinical trials, it has been shown that up to about 90% of patients on infliximab experienced a 75% improvement in their psoriasis.


Some people may produce antibodies to infliximab that decreases its effectiveness over time.



Certolizumab (Cimzia®) was FDA approved in 2018 for treatment of psoriasis.


It is an injectable treatment at 400mg every 2 weeks.


In clinical trials, about 80% of patients on certolizumab experienced a 75% improvement in their psoriasis.



IL-17 inhibitors


There are currently 3 biologic agents in this class:

  • Secukinumab (Cosentyx®)

  • Ixekizumab (Taltz®)

  • Brodalumab (Siliq®)


Secukinumab (Cosentyx®) is an antibody that blocks IL-17.


It is a self-administered injection of 300mg given once weekly for 5 weeks, followed by 300mg once every 4 weeks.


In clinical trials, about 75 to 80% of patients experienced a 90% improvement in their psoriasis after 4 months and 1 year of use.



Ixekizumab (Taltz®) is also an antibody that blocks IL-17.


It is a self administered treatment of a loading dose at 160mg initially, followed by 80mg every 2 weeks for the first 3 months, then 80mg once every 4 weeks.


In clinical trials, up to 90% of patients on ixekizumab experienced a 75% improvement in their psoriasis.



Brodalumab (Siliq®) is an antibody that blocks the effect of IL-17.


It is an injectable treatment at 210mg given once a week for the first 3 weeks, then every 2 weeks after that.


In clinical trials, up to 85% of patients on brodalumab experienced a 75% improvement in their psoriasis.


In the United States, there are concerns that of risk of suicidal thoughts and behavior with brodalumb use.


As such, any person using brodalumab needs to participate in a suicide risk evaluation program.



IL-23 inhibitors


There are 4 medications in this class of biologic agents:

  • ustekinumab (Stelara®)

  • guselkumab (Tremfya®)

  • tildrakizumab (Ilumya®)

  • risankizumab (Skyrizi®).


Ustekinumab (Stelara®) was the first of this class of biologic agents and is an antibody that blocks IL-12 and IL-23.


It is available in 2 doses (45mg and 90mg) and the dose used is dependent on a person’s body weight.


The treatment is an injection administered as a single dose, followed by a second dose after 4 weeks, then every 12 weeks thereafter.


In clinical trials, about two-thirds of patients on ustekinumab experienced a 75% improvement in their psoriasis.


In the United States, ustekinumab is also FDA approved for use to treat children twelve years and older with moderate to severe psoriasis.



Guselkumab (Tremfya®) is an antibody that blocks IL-23.


It is administered as an injection of 100mg initially, then after 4 weeks, followed by one dose every 8 weeks thereafter.


In clinical trials, about 85% of patients on guselkumab experience a 90% improvement in their psoriasis.



Tildrakizumab (Ilumya®) is also an antibody that blocks IL-23.


It became approved for treatment of psoriasis in 2018 in the United States, and is given as an injection of 100mg initially, then after 4 weeks, every 12 weeks thereafter.


In clinical trials, about two thirds of patients on tildrakizumab experience a 75% improvement in their psoriasis.



Risankizumab (Skyrizi®) is also an antibody that blocks IL-23.


It is one of the newest treatments for moderate to severe psoriasis, and was FDA approved in 2019 in the United States.


It is also an injectable medication at a dose of 150mg initially, then after 4 weeks, and every 12 weeks thereafter.


In clinical trials, about 75% of patients on Risankizumab had a 90% improvement in their psoriasis.



In conclusion, there are so many treatment options available for mild to severe psoriasis these days, and the treatment can be selected based on your psoriasis type and severity.




I hope the information provided here has been helpful in giving you a broad overview of the treatment options available to treat people with mild to severe psoriasis. I also hope this information empowers you when you make your medical decisions with your dermatologist.



[1] Weinstein GD et al. Tazarotene cream in the treatment of psoriasis: Two multicenter, double-blind, randomized, vehicle-controlled studies of the safety and efficacy of tazarotene creams 0.05% and 0.1% applied once daily for 12 weeks. J Am Acad Dermatol. 2003;48(5):760. [2] Freeman AK et al. Tacrolimus ointment for the treatment of psoriasis on the face and intertriginous areas. J Am Acad Dermatol. 2003;48(4):564. [3] Mrowietz U et al. An experimental ointment formulation of pimecrolimus is effective in psoriasis without occlusion. Acta Derm Venereol. 2003;83(5):351. [4] Siegfried EC, Jaworski JC, Hebert AA. Topical calcineurin inhibitors and lymphoma risk: evidence update with implications for daily practice. Am J Clin Dermatol. 2013;14(3):163. [5] Lebwohl M et al. Consensus conference: acitretin in combination with UVB or PUVA in the treatment of psoriasis. J Am Acad Dermatol. 2001;45(4):544. [6] Rosmarin DM et al. Cyclosporine and psoriasis: 2008 National Psoriasis Foundation Consensus Conference. J Am Acad Dermatol. 2010;62(5):838. [7] Papp K et al. Efficacy of apremilast in the treatment of moderate to severe psoriasis: a randomised controlled trial. Lancet. 2012;380(9843):738.

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