There are a variety of topical treatments and systemic therapies available to help treat psoriasis. Long-term management of psoriasis requires individualization of therapy, taking into account the extent of the disease, the patient’s perception of the severity and the potential side effects of the treatments.
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The chronic nature of the disease necessitates adoption of a long-term approach while avoiding dramatic short-term fixes that may produce a more reactive disease state. It is often necessary to combine treatments for psoriasis patients.
There is a need for new therapies, and these will eventually come with recent and future medical advances. Approximately 40 percent of patients reported frustration with the ineffectiveness of their current treatment.
While there is no cure, current treatments may offer significant relief. The primary goal of treatment is to regulate or stop the skin cells from growing and exfoliating too quickly while reducing inflammation.
Topical treatments — medications applied to the skin — are usually the first method used to help relieve skin symptoms. There are several topical treatments for psoriasis that have been shown to be effective. While many can be purchased at your local drugstore, others require a prescription.
Topical prescription steroid creams work well for mild, limited cases. As anti-inflammatory agents, they reduce the swelling and redness of skin lesions.
Secondly, vitamin D-3 analogs, or calcipotriene, affect skin-cell differentiation through the regulation of epidermal responsiveness to calcium. Crude coal tar, antralin, tazarotene or retinoic acid (topical vitamin A preparations) and salicylic acid are all anti-inflammatory topical treatments that regulate cell turnover and can also be beneficial in the treatment of psoriasis.
Over-the-counter topicals come in many forms. Salicylic acid and coal tar are the two active ingredients approved by the FDA for the treatment of psoriasis. Products that contain aloe vera, jojoba, zinc pyrithione and capsaicin are used to moisturize and soothe irritated skin and potentially remove scales or relieve itching.
Sunlight therapy involves exposing your skin to small amounts of natural sunlight for approximately 20 minutes per day, depending upon time of year and distance from the equator. And it may help improve psoriasis symptoms, as UV light is anti-inflammatory in small doses.
There are also many indoor sources, including monitored phototherapy units, which emit a specific type of UV light that has been shown to be more effective. These sessions can occur in the home or at the dermatologist’s office.
It is important to note that these wavelengths of light are not found in your local tanning-bed facility. The lights in tanning beds are not regulated and may result in sunburn, which can trigger a psoriasis outbreak. It is very important not to sunburn if you have psoriasis.
Ultraviolet light A (UVA) — also in sunlight — is another option for sunlight therapy. But unlike UVB, UVA needs to be used with a light-sensitizing medication (psoralen), given either topically or orally. This process, called PUVA, slows down excessive skin-cell growth and can clear psoriasis symptoms for varying periods of time. PUVA is most beneficial for those with stable plaque psoriasis, guttate psoriasis and psoriasis of the palms and soles.
The treatment is not without side effects, though, and can cause nausea, itching and redness of the skin. Ginger can help with the nausea, and antihistamines, oatmeal baths or topical capsaicin products may relieve itching. Try compression hose for swollen legs caused by standing during PUVA treatment.
Photochemotherapy with ultraviolent light and the ingestion of psoralen or topical psoralen for moderate to severe psoriasis is highly effective. This can be performed with different wavelengths of light, such as narrow-band UVB.
Finally, the excimer laser can be used to target smaller or a limited number of psoriatic plaques. This laser is found at your local dermatologist’s office and may be covered by insurance in many cases.
Systemic treatments affect the entire body, not just the skin. Biologic agents for moderate to severe psoriasis include: etanercept (Enbrel), adalimumab (Humira) and ustekinumab (Stelara). These have dramatic responses to both psoriasis and psoriatic arthritis.
These are expensive agents, but are quite good for cases with significant skin involvement or for patients with comorbidities like psoriatic arthritis. Tuberculosis skin testing and hepatitis B titers are required prior to initiation of therapy.
During the course of therapy labs are typically monitored, which include complete blood counts and liver-function tests until the medication is well tolerated and the lab values are stable. These medications lower one’s immune system and slightly increase the risk of developing lymphoma. These agents are injected into the subcutaneous tissue either at home or at the dermatologist’s office.
Methotrexate, which blocks DNA synthesis, still remains a viable option for patients. This medication is either taken by mouth or injected into the skin by the patient. However, it is important to rule out liver or kidney disease prior to initiation. In addition, methotrexate increases one’s risk of developing skin cancer. Thus, patients with a strong personal or familial risk of skin cancers should reconsider this treatment option.
New oral “small molecule” treatments have emerged that can selectively target molecules inside immune cells. These treatments slow overactive immune responses and target inflammation within the cell. This lessens the redness and scaliness of plaques and relieves joint tenderness and swelling.
Apremilast (Otezla) is the newest prescription oral medicine approved for the treatment of adult patients with moderate to severe plaque psoriasis/arthritis. Apremilast treats psoriatic arthritis by inhibiting an enzyme that controls much of the inflammation within cells.