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Psoriasis treatment

Psoriasis Treatment Options: Which Regimen Can Help Clear Your Symptoms Effectively?

Psoriasis is a multifactorial condition that primarily affects the skin. Up to 40% of patients develop psoriatic arthritis and other complications over time. It is treatable but not curable, and its manifestations can compromise a patient’s way of life. 

Your medical experts at BHSkin Dermatology understand that being free of these symptoms can be empowering. Here, we discuss the different psoriasis treatment options to guide you in deciding which regimen is best for you.

psoriasis-women-her-elbows-sitting-bedroom-floor-concept-dermatology

What Is the Main Cause of Psoriasis?

Psoriasis has strong autoimmune features and tends to run in families. Environmental factors like stress, trauma, infection, smoking and medications can also trigger psoriasis flares. But its exact cause remains unclear up to now.

Psoriasis lesions develop after exposing the skin’s innate immune cells, aka the “dendritic cells,” to an environmental trigger. In turn, they activate the T-cells, which respond by mobilizing other immune cells. The process results in an increase in pro-inflammatory substances in the skin. The most important of these is TNF-α, which is mostly responsible for the development of plaque psoriasis, psoriatic arthritis and other systemic symptoms.

How Do Physicians Diagnose Psoriasis?

Physicians diagnose psoriasis based on clinical grounds. That means that the history of the lesion and relevant physical exam findings are usually enough to come to a conclusion. Classic presentations generally do not require further testing, although vague-looking lesions may need a biopsy for proper treatment.

The typical psoriasis lesion has the following characteristics:

  • Distinct borders
  • Has white or silver scales
  • Red or pink
  • Raised with a flat top
  • Itchy or painful
  • Removing the scales can make the lesion bleed (Auspitz sign)

Shape and size vary. Distribution-wise, psoriasis lesions generally affect both sides of the body symmetrically. So if you have a plaque on your right elbow, you will see one on the same spot on the left, too.

Extra lesions may develop at sites of trauma or injury—a manifestation called “Koebner phenomenon” or “Koebnerization.” Examples of traumatic events that  can cause Koebnerization are scratching, sunburning and surgical incisions.

Psoriasis can mimic many skin conditions, e. g. skin cancer and atopic dermatitis. Misdiagnosis and treatment delays lead to complications, so its management is best left to board-certified dermatologists, the true skin disease experts.

What Are the Different Types of Psoriasis?

We tackled this subject in-depth in our article explaining the psoriasis treatment process. But we describe them briefly below.

Psoriasis Vulgaris

This is also known as “chronic plaque psoriasis.” It is the most common type, affecting 90% of patients. The classic lesions appear on the scalp, trunk and outer joint (extensor) surfaces.

Chronic Plaque Psoriasis

Inverse Psoriasis

The lesions appear in major skin folds and inner joint (flexural) surfaces. They look shiny and less scaly because of the abundance of oil glands in these sites.

Guttate Psoriasis

Guttate psoriasis lesions are 0.5-1.5 cm in size and usually appear on the trunk and limbs. The condition affects young people, typically erupting after a strep throat infection. Mild guttate psoriasis may resolve on its own after 6-12 weeks. Topical corticosteroids, vitamin D-like medications and phototherapy may be given for stubborn or widespread lesions.

Small Plaque Psoriasis

The plaques look like guttate psoriasis lesions, except they are thicker, scalier and slow-growing. Small plaque psoriasis affects older people, particularly those of Asian descent.

Sebopsoriasis

Sebopsoriasis lesions grow in oil gland-rich areas like the skin folds and center of the face, so they typically have greasy scales.

Napkin Psoriasis

This is a rare skin condition affecting the diaper area, trunk and limbs in babies 3-6 months old. It has a good treatment response, resolving after 12 months of age.

Linear Psoriasis

As the name implies, the plaques have a linear shape. They usually appear in the trunk and limbs.

Pustular Psoriasis

Pus-filled lesions called “pustules” develop on the surface of chronic plaques. Localized pustular psoriasis is confined only to certain areas like the hands and feet. Generalized pustular psoriasis lesions are more extensive and can be fatal, especially if the pustules rupture and become infected.

Erythrodermic Psoriasis

This is a rare illness that can aggravate pre-existing psoriasis of any type. The lesions are widespread and diffusely inflamed. Heart failure is a complication of erythrodermic psoriasis, so it is potentially life-threatening.

Erythrodermic Psoriasis
Erythrodermic Psoriasis

Psoriasis may also be classified in terms of severity.

  • Mild—less than 10% of the total body surface area (TBSA) is involved. To estimate TBSA, compare the area to your palm, which has roughly 1% TBSA.
  • Moderate—affects 10-30% TBSA
  • Severe—lesions are found on greater than 30% TBSA

Psoriasis treatments can only clear existing plaques, prolong remissions and help patients stay on their normal routine. They don’t lead to a cure. When looking for the right psoriasis therapy, your doctor will determine the severity of your symptoms, how the condition impacts your life and how to avoid serious side effects.

Overview of Psoriasis Treatments

Treatment Type Treatment Targets Indications Most Widely Used Treatments
Topical Treatment Abnormal skin cells, hyperactive immune system or both Sole therapy for mild psoriasis without significant lifestyle

compromise

Part of combination treatments for severe, resistant or life-threatening disease

Corticosteroids

Vitamin D-like drugs

Vitamin A-like agents

Skin cell growth inhibitors

Keratolytics

Emollients

Topical calcineurin inhibitors

Phototherapy Moderate to severe psoriasis

Part of combination treatments for severe, resistant or life-threatening disease

UVB

PUVA (psoralen plus UVA)

Excimer laser

Goeckerman treatment

Climatotherapy

Systemic Therapy Moderate to severe psoriasis unresponsive to phototherapy

An alternative if phototherapy is unavailable

Part of combination treatments for severe, resistant or life-threatening disease

Methotrexate

Acitretin

Cyclosporine

Apremilast

Biological Response Modifiers Hyperactive immune system Treatment-refractory psoriasis

Part of combination treatments for severe, resistant or life-threatening disease

Etanercept

Infliximab

Ixekizumab

Secukinumab

Ustekinumab

What Psoriasis Treatment Options Are Currently Available?

Psoriasis treatments inhibit abnormal skin cell growth, immune activity or both. They are classified under the following categories:

Agents Used for Topical Treatment

use-emollient-dry-flaky-skin-as-treatment-psoriasis-eczema-other-dry-skin

Topical therapy may be considered initially for mild to moderate psoriasis. Your healthcare provider may also combine topical medications with other treatments to quickly relieve widespread or life-threatening symptoms. Below are the most commonly prescribed topical medications for this condition.

Corticosteroids

Topical steroids suppress the immune system and skin cell growth in the treated areas. Examples are clobetasol and betamethasone, which are available in creams, foams and other formulations. Prolonged use may lead to skin thinning and irritation, loss of effectiveness (tachyphylaxis) and, rarely, suppression of the body’s stress responses.

Vitamin D-Like Drugs

Vitamin D-like agents inhibit the proliferation and abnormal transformation of the skin cells. They are often combined with steroids and other therapies. Calcipotriene and tacalcitol are the most commonly used in this class for psoriasis treatment.

These agents resemble the skin’s vitamin D, so they can block ultraviolet (UV) light and interfere with phototherapy. You must use them after, and not before, your phototherapy sessions if you are prescribed the combined regimen.

Excessive or prolonged use may lead to skin irritation and blood calcium elevation.

Vitamin A-Like Medications

Tazarotene gel is a retinoid commonly used for the topical treatment of psoriasis. It curbs both skin cell proliferation and the immune cells’ secretion of pro-inflammatory chemicals. It can counter the skin-thinning effects of corticosteroid therapy when they are combined. Its most common side effect is local tissue irritation.

Skin Cell Growth Inhibitors

These agents block DNA synthesis, limiting the growth of skin cells. Coal tar and anthralin belong in this category. Doctors prescribe them less these days because of unpleasant side effects like odor, uncontrolled spread and localized skin irritation.

Keratolytics

These drugs remove psoriatic scales and speed up the shedding of excess skin. They usually contain salicylic acid, which is effective against mild scalp psoriasis. Excessive use or accidental ingestion may lead to systemic toxicity, signified by symptoms such as nausea, vomiting, confusion, diarrhea, ringing of the ears, etc.

Emollients

Emollients reduce moisture loss and prevent skin breakage that leads to more inflammation. Examples are ceramides, baby oil and moisturizing cream. You may apply a layer of these softeners right before putting on another topical medication.

Topical Calcineurin Inhibitors

This newer class of T-cell-inhibiting drugs includes tacrolimus and pimecrolimus. Their use is limited to inverse psoriasis and plaques appearing on the face and skin folds, where they are most effective.

The usual side effects of topical calcineurin inhibitors are mild discomfort and local irritation. But they have an FDA black box warning due to rare reports of lymphoma and skin cancer developing among patients. Moreover, they are recommended only as second-line therapy for various skin conditions and cannot be given to children younger than two.

However, the AAD states that dermatologists have not seen an increased cancer risk in people who use these medications topically.

Patients with moderate to severe symptoms experience only modest and brief improvement when topical medications alone are used. However, combining them with other treatments produces better results and fewer side effects.

Phototherapy

girl-solarium-tanning-solarium-phototherapy-procedure-medical-cosmetology-center

Phototherapy is the first line of treatment for moderate to severe disease and mild cases that fail to resolve with topical drugs. Scalp and nail psoriasis also respond to this modality. It works by suppressing the immune system and aberrant skin cell growth. Its therapeutic and cosmetic effects last several months. Its side effects are mostly limited to the skin.

The most common radiation type used is narrowband UVB because of its cost-effectiveness and safety. UVA is another option, but the need for psoralens, which are potentially carcinogenic photosensitizing chemicals, makes it a little less safe.

Excimer laser treatment is a modified form of UVB phototherapy that works great on small psoriatic lesions. The Goeckerman treatment combines broadband UVB therapy with a topical medication like coal tar.

Climatotherapy entails moving to a place where the climate promotes skin healing. Patients are exposed to sunlight rather than just UV radiation. But the climate modifies the mixture of light rays reaching the skin, preventing sun damage while optimizing its therapeutic effects.

The most frequent side effects of phototherapy are redness and swelling. It also has a small risk of skin cancer but limiting the regimen to once yearly reduces this risk.

Drugs Used for Systemic Treatment

pills-viral-disease-hand

Systemic agents may be considered for psoriasis patients not relieved by topical and UV light therapy or when the latter is not available. They may also be given when arthritis or other complications start to manifest. The drugs in this class affect the entire body, so their side effects are more widespread. Oral and injectable forms are available, but patients prefer the former.

Below are the most widely prescribed systemic medications for psoriasis.

Methotrexate

Methotrexate disrupts DNA synthesis, suppressing skin and immune cell proliferation. Excessive intake can injure the bone marrow, liver and kidneys. Once you start on methotrexate, your healthcare provider will take blood tests periodically to monitor the health of these vital organs.

Acitretin

Acitretin reduces skin cell growth and only modestly affects the immune system. It is commonly combined with phototherapy. Like other systemic retinoids, it can cause birth defects. Women on this medication must use birth control during therapy and up to three years after. Acitretin may also cause hair loss, nail thinning, lip fissuring and liver and muscle damage.

Cyclosporine

Cyclosporine modulates skin cell growth while inhibiting the T-cells. Your healthcare provider may give it for a brief period to induce remission. Side effects include nerve injury, uric acid elevation and inappropriate hair growth. Taking it continuously for more than a year can cause significant kidney damage.

Apremilast

Apremilast is an anti-inflammatory drug that targets TNF-α activity, among others. It effectively treats scalp and nail psoriasis and psoriatic arthritis. Its side effects are minor and include an upset stomach and vulnerability to upper respiratory infections.

Remission of severe psoriasis is possible with systemic therapy. However, your doctor may lower the dose, use combined regimens or shorten the treatment course to reduce collateral organ damage.

Biological Response Modifiers

Biologics comprise a special class of systemic psoriasis drugs. They are extracted or synthesized from biological sources and reserved for severe psoriasis unresponsive to other interventions. They block T-cell activation, TNF-α’s effects and other inflammatory mechanisms. Agents in this class include the injectables secukinumab, ustekinumab, infliximab, etanercept, etc.

Immunosuppression is the main outcome of biologic therapy. Before starting patients on these medications, they must first be tested for HIV and opportunistic infections like tuberculosis and blood-borne hepatitis. Patients must avoid live vaccines while on this type of treatment.

Cancer risk increases when the immune function is depressed. Biologic therapy may also worsen psoriasis symptoms or lead to autoimmunity against the blood cells and vital organs.

Psoriasis treatments range from targeted therapies to broad-acting medications, so their safety profiles also vary. Working with a highly trained psoriasis specialist will help you clear your symptoms while minimizing the side effects.

Does Psoriasis Treatment Require Downtime?

Psoriasis therapy corrects abnormal immune system and skin cell activity—the processes underlying the symptoms—and not specific lesions. The condition may present with widespread plaques and systemic complications. So medical dermatology treatments are more appropriate than dermatologic surgery. This means you have no surgical wound to care for during treatment.

However, some psoriasis medications may cause toxicity or severe weakness, which can disrupt your normal routine indefinitely. Get a bona fide psoriasis expert to make sure you minimize the side effects of therapy.

What Is the Best Treatment for Psoriasis?

There is not one form of psoriasis therapy that works for every patient. But we can consider the following to be best suited for specific situations:

  • Topical corticosteroids

Topical corticosteroids are the first-line agents for psoriasis treatment. Their side effects are usually mild, and they are useful regardless of disease severity. You can use them alone for mild symptoms or combined with other therapies for moderate to severe psoriasis.

  • UVB Phototherapy

UVB light therapy is highly effective for widespread lesions and those resistant to topical therapy. Most of its side effects are tolerable, while the rest, e. g. skin cancer, are preventable.

  • Acitretin

Erythrodermic and pustular psoriasis respond well to this retinoid, so it is the first-line medication for managing these conditions.

  • Cyclosporine

Short courses of this drug are recommended for inducing quick remission of severe, life-threatening psoriasis. Its potential side effects make it less preferable for long-term treatment than other non-biologic medications.

  • Methotrexate

This drug is best for the long-term management of chronic plaque psoriasis. It may also be given to patients with erythrodermic or pustular psoriasis to prevent the side effects of prolonged acitretin or cyclosporine use.

  • Biological response modifiers

Biologics are your last resort medications for systemic symptoms that won’t go away with other treatments. They shut down your entire immune system, which is why they are very effective. But this also makes you vulnerable to a host of unwanted side effects.

Various factors help determine the most suitable psoriasis treatment, such as:

  • The severity of your symptoms
  • The success and adverse effects of any past treatments
  • Medical conditions that can make you unfit for some forms of therapy
  • If combined treatments are safe for you
  • Your quality of life while on therapy, as some side effects may severely restrict your activities
  • Costs. Health insurance usually covers psoriasis treatment, but policy coverage varies.
  • Availability of the treatment. For example, some small rural facilities do not have phototherapy services.

At BHSkin Dermatology, we offer a wide array of psoriasis treatments, including phototherapy. Your psoriasis specialist will examine you thoroughly and discuss all options before initiating your regimen.

Severe Psoriasis Before and After Phototherapy
Severe Psoriasis Before and After Phototherapy

Why Should You Treat Psoriasis Right Away?

Treating psoriasis promptly helps you ensure that:

  • You minimize systemic inflammation associated with this illness. Chronic systemic inflammation makes patients prone to complications like heart disease, psoriatic arthritis and cancer.
  • You avoid advanced disease, which responds poorly to therapy and may lead to potentially fatal complications.
  • You have better control of your symptoms, so you won’t need expensive, highly aggressive immunosuppressants.

The sooner your symptoms resolve, the more confident you will feel about your physical and mental health.

What Are the Risks of Medical Treatments for Psoriasis?

The medical treatments we described above have been proven by clinical trials to be effective, though they are not risk-free. The following are their biggest downsides:

  • Some can produce serious side effects. We have mentioned the most important ones above.
  • Some are costly, particularly biologics.
  • Not all treatments are accessible everywhere. For example, some geographic locations don’t have phototherapy services. Not all pharmacies offer biologics.

But the most serious risks are typically due to aggressive therapies. You can minimize them by getting treated promptly and working with a trusted board-certified dermatologist.

How Important Is It to Have a Psoriasis Expert Treat You?

Psoriasis requires balancing the effectiveness of therapy with its potential side effects, which only a true specialist can do. Additionally, you will need continuous care for this complex, lifelong illness. Finding the right psoriasis expert who will work with you for the long haul helps ensure you get optimal treatment in a timely fashion every time.

Frequently-Asked Questions About Psoriasis Treatment

We answer below the questions commonly asked by patients about psoriasis treatment.

How Do You Stop Psoriasis Flares?

Psoriasis breakouts often have identifiable triggers. They include the following:

  • Infection, most commonly strep, staph, fungal and HIV
  • The use of some medications
  • The abrupt withdrawal of steroids
  • Skin trauma
  • Cadmium and other pollutants
  • BCG, Moderna and AstraZeneca vaccines
  • Smoking

You can minimize flare-ups by treating infections promptly and avoiding other potential psoriasis triggers.

Good skin care also helps because psoriasis patients have sensitive skin. The routine generally consists of gentle cleansing, moisturizing, sun protection and using topical anti-inflammatory vitamins like niacinamide.

Which Test Is Best for Psoriasis?

Psoriasis is a clinical diagnosis, meaning history and physical examination are all the physician needs for disease identification. Confirmatory tests are not necessary, though atypical presentations require a biopsy to rule out skin cancer.

Can Psoriasis Be Cured?

There is no known cure for psoriasis. However, years-long remission is possible in many cases.

Can You Get Rid of Psoriasis Naturally?

The National Psoriasis Foundation lists the following natural remedies people have used to improve psoriasis lesions:

  • Aloe vera
  • Apple cider vinegar
  • Capsaicin
  • Dead Sea salts
  • Oats
  • Tea tree oil
  • Turmeric
  • Oregon grape

Theoretically, these treatments help curb skin inflammation, but the evidence for the efficacy and safety of each, when used alone for psoriasis therapy, is lacking.

Still, if you experience symptom relief from using them, you may combine them with FDA-approved treatments to ensure you get the benefits of both alternative and medical therapy.

Is Sun Good for Psoriasis?

Simple sun exposure is not the same as UVB phototherapy or climatotherapy.

The sun emits UVB light. However, it also radiates other light rays, which reduce the healing efficiency of UVB light while creating greater damage to the skin. Sunburns can cause Koebnerization and worsen psoriasis plaques. Meanwhile, chronic sun damage can create other stubborn lesions ranging from mild pigmentation changes to skin cancer.

Climatotherapy likewise differs from simple sunlight exposure. For example, Dead Sea climatotherapy takes advantage of the sea aerosol’s ability to screen out light rays not needed in clearing psoriasis lesions. Studies show that this form of treatment shortens the duration of psoriasis flare-ups.

There’s no harm in getting some sun—you need it to activate the skin’s vitamin D for your bones. But remember the risks of having too much.

Koebnerization in a sunburned area
Koebnerization in a sunburned area

How Do You Get Rid of Psoriasis in Kids?

Pediatric psoriasis is more complicated to treat because of the increased side effect risk in this population and the lack of international therapeutic guidelines.

In the US, the treatment options are similar to adults. Mild cases are treated with topical corticosteroids with or without vitamin D-like drugs. Phototherapy and systemic medications are prescribed for severe or resistant lesions.

Methotrexate, acitretin or cyclosporine may be given at the lowest effective dose. Among biologics, the only FDA-approved ones for pediatric psoriasis are etanercept, ustekinumab, ixekizumab and secukinumab.

What Is the Latest Treatment for Psoriasis?

The FDA approved deucravacitinib on September 9, 2022 for the systemic therapy of moderate to severe plaque psoriasis. It is an orally formulated selective biological response modifier. It has the combined advantages of the systemic medications we described above.

Clinical trials show that deucravacitinib is more effective than the older oral medication apremilast in relieving psoriasis symptoms, particularly itching, and improving quality of life. But it does not cause serious side effects associated with non-selective biologics.

What Is the Best Treatment for Psoriasis on the Hands and Feet?

Psoriasis of the hands or feet generally requires potent treatments. The skin in these areas is very thick, making drug penetration difficult. Additionally, lesions in the palms and soles produce pain and restrict movement in many patients.

Doctors may prescribe high-potency topical steroids like betamethasone for small lesions, with or without a vitamin D-like drug. Phototherapy and systemic medications may be started if the condition fails to improve with topical corticosteroid treatment. Over-the-counter painkillers and physical therapy help alleviate pain.

Do Any Vitamins Help With Psoriasis?

Currently, vitamin supplementation does not have an established role in psoriasis therapy. Three anti-inflammatory vitamins—omega-3 fatty acids, selenium and beta-carotene—are apparently associated with symptom improvement in some psoriasis patients. But these observations have yet to be proven in large-scale clinical studies.

Meanwhile, despite topical vitamin D’s therapeutic effects, the benefit of oral vitamin D supplementation in psoriasis patients remains unknown.

Note that vitamin supplementation without evidence of deficiency can do more harm than good. Consult your doctor before taking any vitamin supplement.

Among dietary changes, those seen as more likely to help psoriasis patients are caloric reduction and adhering to the Mediterranean diet.

Obesity increases the risk of developing severe psoriasis, while caloric restriction is associated with symptom clearance. On the other hand, the Mediterranean diet not only helps you stay fit but also increases the body’s omega-3 fatty acids naturally.

A balanced diet and maintaining a healthy weight reduce the risk of developing severe psoriasis
A balanced diet and maintaining a healthy weight reduce the risk of developing severe psoriasis

Can Removing Your Tonsils Cure Psoriasis?

In psoriasis patients, the tonsils can potentially harbor abnormal T-cells that can aggravate the disease. They are likewise targets for strep infection.

However, the evidence for the effectiveness of tonsillectomy in clearing psoriasis plaques is still insufficient, theoretically sound though the idea may be. So currently, there are no recommendations for its routine performance on psoriasis patients.

Psoriasis Treatment: The Bottomline

Psoriasis is a multifactorial condition with prominent autoimmune and genetic characteristics. There is no magic bullet that can cure all forms of this illness. However, the primary management goals are to treat the symptoms, maintain or improve patients’ quality of life and minimize side effects. Currently available therapies focus on suppressing immune function and abnormal changes in skin cells.

If left unresolved, psoriasis will increase your risk of developing severe complications. But getting help early gives you better control of your symptoms and lets you avoid unwanted side effects from aggressive treatments. That said, only when you work continuously with a highly trained psoriasis specialist can you be sure of having long symptom-free periods.

The Best Place to Get Effective Psoriasis Remedies in LA

Psoriasis is a complex illness that can take the fun out of life if left untreated. There are no confirmatory tests for this condition, so diagnosis and therapy depend mostly upon your healthcare provider’s clinical expertise.

At BHSkin Dermatology, our award-winning board-certified dermatologists have helped many psoriasis patients in LA. Visit us at our Glendale or Encino clinic or use our telederm portal for a consultation.

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