What You Need to Know About Oral Medications for Psoriasis

“Oral medications are tailored to reduce symptoms in moderate to severe cases of psoriasis,” says Nina K. Antonov, M.D., a board-certified dermatologist at Modern Dermatology in Westport, Connecticut. “Unfortunately, there are many side effects associated with oral medications that treat psoriasis symptoms, so you will need to work with your doctor to weigh the risks and potential rewards and see what works best for you.”

Usually, oral systemic medications are offered to people who have not had a response to topical medications or UV light therapy or who aren’t candidates for biologic therapies (for example, due to needle phobia or loss of response to biologics).

Here, we take a closer look at some of the most popular oral medications used to treat psoriasis—whether alone or in combination with other treatments—and what you need to know about them.

1. Cyclosporine (Brand names: Gengraf, Neoral, and Sandimmune)

Cyclosporine is a fast-acting medication that works well to relieve symptoms within a few weeks, but it’s not a long-term solution, says Karan Lal, D.O., a board-certified dermatologist at UMass Memorial Medical Center in Worcester, Massachusetts and marketing committee chair for the Society for Pediatric Dermatology. It is often used as a bridge to safer, long-term treatment options, since it can cause serious side effects to your kidneys if taken for too long.

Cyclosporine is usually reserved for severe cases of psoriasis. Because it suppresses the immune system, it can make patients more prone to infection. People taking cyclosporine are monitored with laboratory tests to check blood counts, kidney function, lipid levels, and electrolytes while they’re on the treatment. This medication is normally given at a dose based on your weight; so, for a 132-pound (60 kg) person, a starting dose could be 100 mg twice daily, for example.

Lal agrees and adds an extra warning: “It does weaken the immune system. It can raise blood pressure, as well, so it must be used with caution in patients with high blood pressure. You also can’t eat grapefruit or drink grapefruit juice if you take this medication, as it can cause more side effects from treatment.”

Cyclosporine may also put you at higher risk for skin cancers, especially if you have a history of having used psoralen-UVA (PUVA) therapy. So, if you’re on this medication, it’s a good idea to get full annual skin exams with your dermatologist.

2. Methotrexate (Brand Names: Otrexup, Rasuvo, Trexall)

Methotrexate is a slow-acting medication which can be used long-term to treat psoriasis. The benefit to this medication is that it’s very affordable. It doesn’t suppress the immune system completely, but rather decreases inflammation. It’s in a drug class called antimetabolites, which can slow the growth of skin cells that cause psoriasis plaques.

Methotrexate takes eight to 12 weeks to start working and is metabolized through the liver, so alcohol consumption should be limited when taking it, says Lal. Plus, anyone taking it should also take folic-acid supplements to prevent toxicity from the medication. Methotrexate is only given once a week (starting doses may be 7.5 mg then go up to 25 mg weekly), but on all the other days, people on it should be taking folic acid.

Over-the-counter medications like NSAIDs (aspirin, ibuprofen, naproxen) should be used with caution in patients on methotrexate, as they could lead to more side effects. Some of the common side effects of this medication include nausea, vomiting, diarrhea, loss of appetite, and abdominal pain. If someone has these side effects, they may be switched to a subcutaneous injection of methotrexate, which will bypass the gastrointestinal (GI) tract and relieve GI symptoms.

Anyone on this medication should have their blood counts and kidney and liver function monitored, adds Antonov. People with active tuberculosis or hepatitis should not be given this medication, so your doctors may check this prior to starting it. Women who are pregnant, breastfeeding, or planning to become pregnant shouldn’t take it either. And men should not get a woman pregnant during treatment and for three months after stopping this drug, since it may be harmful to an unborn baby.

3. Apremilast (Brand Name: Otezla)

Apremilast is a newer medication that doesn’t weaken the immune system. Instead, it works to decrease the body’s response to inflammation associated with psoriasis and psoriatic arthritis. It’s important to note that approximately 30 percent of people with psoriasis have psoriatic arthritis.

Apremilast is similar to methotrexate in that it’s very slow to work, so patience is key to success. Usually, the prescription is first given as a starter pack used to slowly ramp up the dose of the medication (i.e., from 10 mg daily to 10 mg twice daily, etc.) until 30 mg twice daily is reached; this helps to limit the common side effects of the medication, including abdominal discomfort, nausea, vomiting, and diarrhea. Some people lose weight while taking it.

It’s generally not given to people with depression, as it can make some mood symptoms worse. There’s no need for any laboratory monitoring while on this medication, except in patients with known chronic kidney disease.

4. Acitretin (Brand Name: Soriatane)

Acitretin is an oral retinoid (a derivative of vitamin A) which increases the skin-cell turnover rate to help clear skin more quickly. Side effects of acitretin range from dry skin, dry lips, and hair loss to mood irregularities and effects on liver function.

“There are serious implications with this medication for women who are pregnant or may become pregnant,” Antonov says. Thus, this medication is usually not prescribed to women of childbearing age.

Lab monitoring includes complete blood counts, liver-function tests, and lipid panels. It can be used alone or in combination with biologics such as etanercept. This medication is dosed daily, with a starting dose from 10 mg up to 50 mg daily.

5. Hydroxyurea (Brand Name: Hydrea)

Hydroxyurea is not FDA-approved for psoriasis but may be used off-label for the treatment of psoriasis. It’s similar to methotrexate in that it is an antimetabolite and works by slowing down cell turnover via its effect on DNA synthesis. It’s given at a starting dose of 500 mg daily, titrated up to 1,500 mg daily. This medication is given until patients show benefit, then they should be slowly weaned.

Required monitoring includes blood counts and a complete metabolic panel (liver and kidney function), because its common side effects include low blood counts, leg ulcers, nail changes, and skin changes. This medication is considered a teratogenic, as well, and should not be given to pregnant women. It may be given in combination with other oral medications, such as acitretin, to improve psoriasis symptoms.

6. Tofacitinib (Brand Names: Xeljanz or Xeljanz XR)

Tofacitinib is FDA-approved for the treatment of psoriatic arthritis, but can be used off-label for skin psoriasis, as well. It’s one of the newer classes of medications in the family of JAK-STAT inhibitors. It works by reducing inflammation by targeting a specific part of the immune system to reduce the body’s overactive response. It can be given as a tablet of 5 mg twice daily or an extended-release capsule of 11 mg daily.

This medication can put you at risk for infections and cancer (i.e. lymphoma) as it weakens your immune system. Your doctor may check for tuberculosis and hepatitis B and C prior to starting the medication. Other side effects include: headache, diarrhea, high blood pressure, nasal congestion, and rash.

There are so many medications used to treat psoriasis, it can be overwhelming. Having a dedicated dermatologist to help figure out what medication may work best for you is very important.

Remember that orals aren’t your only option for treating psoriasis. You might also want to explore topicals, phototherapy, and biologics. The best treatment for you will depend on your symptoms, other health conditions, other concurrent medications, and your psoriasis severity. Plus, any treatment regimen for your psoriasis should fit into your daily life—and, be prepared that it might take trying different options to find the perfect fit.

Antonov adds that treating psoriasis isn’t just about taking medication; it typically requires a comprehensive plan that includes healthy lifestyle and diet choices, as well. For more information on these and other psoriasis treatments, talk to your dermatologist.

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