A Simple Guide to Finding the Right Psoriasis Medication for You

Topicals

Topical therapies are medications applied directly to the skin to help tame inflammation and soothe psoriasis symptoms.

“There are several topical treatments that exist for psoriasis, and they come in various potency scales,” explains Saakshi Khattri, M.D., assistant professor of dermatology at the Icahn School of Medicine at Mount Sinai Hospital in New York City. Topicals range from simple over-the-counter emollients like petroleum jelly to more potent prescription corticosteroids.

“The fastest-acting is a topical steroid, but they’re not really safe for long-term use because of side effects like skin-thinning and systemic absorption,” explains Khattri. Since steroids are absorbed by the skin and into the body, they may affect your internal organs. So while they’re effective in treating active psoriasis lesions, once your skin clears up, your doctor may recommend changing the frequency of topical steroid use, or switching to a nonsteroidal option like a vitamin D analog, topical retinoid, or anthralin.

For most topicals, a typical regimen is to apply twice daily, though some people with psoriasis have a hard time sticking to that schedule—especially if they’re prescribed multiple topicals.

Using topicals as directed may successfully control more mild forms of psoriasis. Topicals can also be used in combination with other psoriasis treatments for more severe cases.

Phototherapy

“Phototherapy has been used in the treatment of psoriasis for the longest time,” says Khattri. It involves consistently exposing psoriasis lesions to ultraviolet rays in a controlled setting and under doctor supervision.

There are a few different types of phototherapy, including natural sunlight exposure, ultraviolet B (UVB) phototherapy, and psoralen plus ultraviolet A (PUVA) phototherapy. “We generally use narrow-band UVB therapy, as it’s proven to be safer compared to PUVA,” says Khattri. Unfortunately, long-term use of PUVA (150-plus sessions) carries a higher risk for developing nonmelanoma skin cancer, cataracts, and premature aging of the skin in comparison to UVB therapy.

A phototherapy session could mean stepping into a full-body unit, or the therapy could be administered via a wand for more targeted treatment. The type of unit and length of each session will depend on your skin type, the severity of your psoriasis, and the type and strength of the phototherapy approach you’re using. During each session, you’ll need to protect areas of your skin that aren’t affected by psoriasis—for example, by using eye goggles and sunscreen.

Unfortunately, phototherapy isn’t the most convenient treatment option for everyone. “One issue with phototherapy is that you typically have to go three times a week when you’re in the treatment phase,” explains Khattri. “Though once you achieve a satisfactory response, the frequency of phototherapy sessions can be tapered down to the lowest frequency that works for a patient to sustain improvement.”

While it is possible to get a phototherapy unit for your home, note that most dermatologists prefer administering phototherapy in an office setting, where sessions are controlled and observed by a trained professional. There are safety concerns with in-home units, and doctors want to make sure patients adhere to important phototherapy treatment guidelines. (And tanning beds aren’t the same thing as phototherapy units, so they aren’t a good idea either.)

“Phototherapy is a safe option—you sometimes might have a slight sunburn afterward, but if that’s the case, we’ll scale back exposure on subsequent visits,” says Khattri. That said, if you have a history of skin cancer, phototherapy may not be the best option for you, as it generally does increase your risk of skin cancer. Even if you don’t have a history of skin cancer, if you use phototherapy, it’s important to undergo regular skin-cancer screenings due to this increased risk.

Traditional Systemics

If you have a more serious case of psoriasis, your dermatologist may prescribe what’s known as a systemic medication. Systemics treat psoriasis from the inside of the body by suppressing your immune system.

Methotrexate is one of the most common oral systemic treatments for psoriasis; other options include acitretin and cyclosporine. Systemic medications for psoriasis are typically administered orally, but there are some psoriatic arthritis systemics that are injected.

“Methotrexate has been used for the treatment of psoriasis for a long time,” explains Khattri, “though it does have a systemic immune-suppressive effect—and it does need frequent monitoring.” That’s because these medications work on a broad level to suppress the overactive immune-system activity related to psoriasis. As a result, your body may have trouble fighting off infections; and, taking these medications can affect your liver, lung, or kidney function. “In my patients who take methotrexate, I monitor their complete blood count and their complete metabolic panel to make sure their kidney and liver enzymes are doing ok,” adds Khattri.

Note that some people who take methotrexate experience GI side effects, like diarrhea, nausea, and vomiting. “Adding folic acid can help limit these side effects,” says Khattri.

Biologics

Technically, biologics are a type of systemic therapy, but they’re a newer class of drugs compared to more traditional systemics—and they’re generally thought to be the most effective option for people with more severe psoriasis.

Biologics work by targeting specific parts of the immune system to interrupt the underlying disease process that contributes to psoriasis. Because they suppress the immune system, biologics may increase your risk of infection. “Patients have to be tested for current infections like hepatitis B, hepatitis C, and tuberculosis before starting biologic treatment,” says Khattri. “Though they don’t need extensive monitoring—for the most part, it’s just blood work every six months.”

The biologics that are approved for treating psoriasis fall into four categories:

• TNF-alpha inhibitors (Cimzia, Enbrel, Humira, Remicade)
• IL 12 and 23 inhibitors (Stelara)
• IL 23 inhibitors (Ilumya, Skyrizi, Tremfya)
• IL-17 inhibitors (Cosentyx, Siliq, Taltz)

“All of these options work very well for skin psoriasis—and some also have an indication for psoriatic arthritis,” explains Khattri. “Depending on how extensive the disease is, and whether there are other comorbidities or underlying conditions, we can choose which biologic makes sense.”

Your personal preference can also play a role in choosing a biologic, since some are available as injections, whereas others are given via IV infusions.

Finding the Right Treatment for You

So which psoriasis medication works best? It can vary from person to person—and some people who have psoriasis may need a combination of a few different types of treatments to help them gain control.

“Even if you’re on a biologic or a systemic treatment, you might still have some psoriasis left behind on your skin that needs a topical,” explains Khattri. Not all treatments can be combined, she cautions, so it’s important to work closely with your dermatologist.

Part of that process includes some trial and error—which is the only way to know which treatment or combination of treatments will work best to control your psoriasis. It’s necessary to try out different options and make adjustments along the way.

And when it comes to noticing results, try to be patient. “With systemics and biologics, it often takes a minimum of three to six months to see a response,” says Khattri.

Even then, if your treatment plan doesn’t seem to be working, or if it stops working, keep an open dialogue with your dermatologist. “Don’t give up,” says Khattri. “Various combinations do exist. If one doesn’t work, we have other options. Be open to trying other things.”

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