Treatments

Only a physician can confirm whether or not you have psoriasis, so if you experience the symptoms described on the Symptoms page, make an appointment to see your doctor, who will give you a physical examination and possibly take a biopsy of the affected skin.

If you have mild psoriasis, you may be able to manage your condition without prescription-strength medication by avoiding things that you know trigger your psoriasis (e.g., stress), bathing regularly, applying moisturizer and exposing your skin to small amounts of sunlight.

However, if your psoriasis is more aggressive, there are several over-the-counter and prescription medications that can help relieve your symptoms.

These medications aim to bring your psoriasis under rapid control, reduce the body surface area it affects, clear your lesions, help to maintain clear skin and avoid a relapse, and improve your quality of life.

They include topical agents that you rub on your skin, oral medications, a type of treatment called “biologics,” and phototherapy.

Below is a brief overview of the different types of treatment most commonly used for psoriasis. Discuss with your doctor which treatment is right for you and what the benefits and side effects may be. Your doctor may suggest one medication, prescribe a combination, rotate between different medications, or use medications in a specific order to clear your skin. After trying one option, don’t hesitate to discuss a different treatment plan with your doctor if the approach you are currently taking is not working.

To get the most out of your therapy, always use your medications as directed by your doctor.

Topical Agents

About 80% to 90% of people have mild to moderate psoriasis, and most can be treated with topical agents—treatments applied on the skin—including creams, gels, ointments, solutions, foams, tapes, sprays, oils, shampoos and lotions. Topical agents may be used alone or in combination with other therapies, such as phototherapy, methotrexate, or biologic medications.

Topical corticosteroids

Corticosteroids are synthetic versions of hormones made in the body and are the most commonly prescribed medications for psoriasis. Corticosteroid creams, lotions, foams, gels, ointments and sprays are the most commonly prescribed topical agents for mild to moderate psoriasis. When applied to the skin, they reduce inflammation in the area, making them useful treatments for some forms of psoriasis. They are available in low-dose, high-dose and very-high-dose preparations.

Corticosteroids usually work quickly, and the low-dose formulations can be applied almost anywhere on the body. For mild psoriasis limited to a few small plaques, low-dose, non-prescription strength may be all that’s needed. However, if the plaques’ crusts are thick or if they’re widespread, high-dose topical steroids may be prescribed alone or in combination with other treatments.

If corticosteroids are used for an extended period over a large area, it’s possible for some of the drug to be absorbed into the body. This is called systemic absorption and it can lead to Cushing’s syndrome, cataracts, glaucoma and osteoporosis. It is important to follow any instructions your doctor gives you about using a corticosteroid cream or lotion. Side effects include:

Fragile, thin skin, easy bruising
Appearance of small blood vessels
Bands of thin, red skin that turn into slivery lines (stretch marks)
Infection of hair follicles
Tiny red or purple spots
Contact dermatitis (rash)
Vulnerability to infections
Hair growth

Topical corticosteroids can worsen rosacea, around-the-mouth rashes, athlete’s foot and similar infections. Higher-potency products are usually limited in use to only two to four weeks at one time to limit the risks of systemic absorption and other side effects. After psoriasis goes away, topical corticosteroids are gradually reduced then stopped to reduce the risk of rebound outbreaks. There is some controversy over whether people can develop a resistance to topical corticosteroids over time.

Vitamin D3 derivatives

Vitamin D3 derivatives, such as calcipotriol, are available as creams, ointments and solutions for the treatment of mild to moderate psoriasis.

Vitamin D3 derivatives are corticosteroid-sparing – they enable you to use less topical corticosteroid. They are usually applied once or twice daily for about 8 weeks. When combined with topical corticosteroids, they work better in people with plaque psoriasis than either agent alone.

They can be very effective but may cause side effects in up to 35% of people. However, side effects often lessen over time.

Side effects include burning, itchiness, swelling, peeling, dryness and rash. They should not be used on the face. In patients who spread larger doses over much of their body, vitamin D3 derivatives may cause a rise in blood calcium levels, which reverses when the medication is stopped. They may also cause light sensitivity and may cause a burning sensation if applied before UVB phototherapy.

Calcitriol ointment, an active form of vitamin D, is also presently available.

Topical retinoids

Topical retinoids may be an effective treatment for mild to moderate psoriasis. At least one topical retinoid, tazarotene, is available in Canada. When combined with topical corticosteroids, tazarotene can help prevent thinning of the skin, which is a common side effect of corticosteroids.

Combining a topical retinoid with UVB phototherapy may enhance benefits and reduce the amount of UV exposure needed for a good response.

A common side effect is skin irritation in or around plaques, which may be lessened by using a moisturizer, applying the product on alternate days, short-contact (30- to 60-minute) treatments or combining this product with a topical corticosteroid.

Pregnant and nursing women cannot take topical retinoids due to the high risk of birth defects.

Systemic Treatments

Systemic treatments are any form of therapy that is delivered orally (in tablet or liquid form) or through injection or intravenous infusion (drip), as opposed to topical treatments, which are applied directly to the skin.

Cyclosporine

Cyclosporine is a prescription drug that suppresses immune responses. It has long been considered one of the most effective treatments for psoriasis for some people, but long-term use carries a high risk of serious kidney, liver and other problems, such as lymph-node cancer, increased blood pressure, and skin cancer. For this reason, cyclosporin is usually limited to short courses and should not be taken for longer than one year, or two, at most. This medication interacts with numerous drugs, so it is important to tell your doctor about other medications and supplements that you take.

Doctors usually prescribe cyclosporin for patients with severe flares or when psoriasis rebounds after other treatments. It often clears the skin rapidly.

Common side effects include kidney damage, liver problems, hypertension, hair overgrowth, headache, higher risk of infection, muscle/bone aches and pains, tremor, tiredness, cough, runny nose, shortness of breath, stomach pain, nausea, vomiting, diarrhea, numbness or tingling in the skin, loss of strength and more. Routine blood tests are prescribed to monitor metabolic problems such as too much magnesium or uric acid in the blood.

Methotrexate

This drug has treated moderate to severe psoriasis for more than 50 years. Methotrexate works by suppressing the immune system—stopping the body from attacking itself—in ways that prevent skin inflammation that leads to psoriasis.

Although effective in many patients, methotrexate may carry a higher risk of infection because it suppresses the immune system. Many experts recommend that people take folate supplements while on this medication to avoid gastrointestinal and bone-marrow problems.

This medication is not for everyone; doctors do not prescribe it to pregnant or nursing women or people with liver or kidney problems, hepatitis, leukemia, or a history of not taking their drugs or alcoholism.

Common side effects include nausea, anorexia, mouth ulcers and tiredness. Serious side effects include liver, kidney, lung, and bone-marrow problems.

Drug interactions are common. Methotrexate becomes more toxic when taken with:

Common NSAIDs, such as ibuprofen, salicylates, naproxen, indomethacin and phenylbutazone
Common antibiotics, including penicillins, sulfonamides, trimethoprim/ sulfamethoxazole, minocycline and ciprofloxacin
Thiazide diuretics, sulfonylureas, phenytoin, barbiturates, furosemide People who take methotrexate must have periodic blood tests to check for liver problems and other side effects.

Retinoids

Oral retinoids, such as acitretin, are derived from vitamin A. They are usually reserved for the treatment of severe psoriasis that covers more than 10% of the body or causes physical, occupational or psychological disability. They are particularly helpful for palm and sole psoriasis. Overall, they tend to be less effective than methotrexate and cyclosporine. Oral retinoids are often combined with UVB or PUVA phototherapy and biologic therapy for greater benefits.

These medications work by slowing the growth of skin cells, preventing skin from swelling and interrupting the body’s attack on itself.

Oral retinoids are safe for long-term use and are often prescribed as maintenance therapy.

When combined with other agents, they work synergistically, enabling the use of lower doses of each drug.

Drug interactions are possible with other psoriasis medications—such as cyclosporine—and people must avoid supplements that contain vitamin A to prevent overdose.

Common side effects—such as dry eye, mouth or nose dryness, nosebleeds, dry skin, swollen or cracked lips, brittle nails, hair loss, nausea, stomach ache, muscle or joint pain, pins-and-needle sensations and itchy, burning, or sticky skin—occur in almost everyone who takes an oral retinoid. A less common side effect is a skin plaque that looks like unstable psoriasis.

Oral retinoids must not be used in women of childbearing age unless they use a reliable form of contraception. Because the drug persists for long periods in the body, women should avoid becoming pregnant while taking acitretin and for a full three years after they have stopped taking it. Women who are nursing also should not take acitretin.

Routine blood tests are used to monitor cholesterol and triglyceride levels as well as liver and kidney function.

Biologics

Biological response modifiers, more commonly referred to as biologics, are the latest entry into the therapeutic arsenal of treating psoriasis and are considered a highly effective treatment option for patients with moderate to severe psoriasis.

Biologics have up to now mainly been used by people who cannot use other treatments or whose psoriasis does not improve with other types of therapy. However, the CSPA is to the provinces to allow dermatologists to decide when and if a biologic agent is a preferred first approach for a given patient.

Biologics are either similar to or the same as proteins in the body’s immune system. They block interactions between certain immune-system cells that prevent the immune system from causing skin inflammation. However, this activity weakens the ability to fight infections. For that reason, before starting biologic therapy, people usually have standard vaccinations for flu, hepatitis A and B, pneumonia, tetanus, diptheria and other infectious diseases.

Before treatment begins, people generally have routine tests to detect liver problems, hepatitis and tuberculous. If you have or develop a serious infection, biologic therapy must stop until you are better.

People with congestive heart failure, multiple sclerosis (MS) or similar diseases, or MS in their family cannot take biologics. These medications should be used cautiously in people with a history or family history of cancer.

Most biologics, including adalimumab, alefacept, etanercept and ustekinumab, are given by injection just under the skin (subcutaneous injection) and can be administered by a nurse or by the patients themselves after proper training. Common side effects include mild skin reactions at the injection site, nausea, upper respiratory tract infection, rash and headache.

Another biologic, infliximab, is given by intravenous infusion or “drip” at a day clinic or hospital rheumatology department under medical supervision. Infusions of infliximab are given at two weeks, then six weeks after the first infusion, then every eght weeks. Each infusion takes about two hours, with an observation period of about one hour or more afterward. Common side effects can include fever, rash, headache, and muscle or joint pain.

Five biologic response modifiers (biologics) are used to treat moderate to severe psoriasis in Canada. They are generally divided into three groups on the basis of how they work:

TNF inhibitors
Interleukin inhibitors
T-cell inhibitors

TNF inhibitors Some biologics, such as adalimumab, etanercept and infliximab, block the action of tumour necrosis factor (TNF) made by the immune system. Some people with psoriasis have too much TNF in their bodies, and this overabundance of TNF can cause skin inflammation. TNF blockers can reduce the amount of TNF in the body to normal levels. TNF inhibitors, which affect the immune system, may affect your ability to fight off infections. Be sure to tell your doctor if you have any sign of an infection or if you have a history of tuberculosis (TB) or hepatitis B. Also let your doctor know if you have infections that keep coming back or if you have a condition like diabetes, which might increase your risk of infections. If you are pregnant or nursing, you should discuss with your doctor whether to stop taking your medication temporarily.

Common side effects:

Adalimumab: pain, inflammation, bleeding or swelling at the site of injection. You may also experience upper respiratory tract infections, headache, rash, nausea, abdominal pains or urinary tract infection.
Etanercept: a mild reaction involving pain, inflammation, bleeding or swelling at the site of injection, infections and upper respiratory tract infections.
Infliximab: Infections, fatigue, joint pain, abdominal pain or back pain.You may also experience shortness of breath, hives or headache following an infusion.

Anti-TNFs have been widely used in other indications such as rheumatoid arthritis or psoriatic arthritis and so have demonstrated longer history with a predictable side effect profile.

Interleukin inhibitors

Interleukin inhibitors, such as ustekinumab, can prevent specific proteins in the body—called interleukins—from causing the body’s immune system to attack the skin and nails.

Drugs like ustekinumab also may affect your ability to fight off infections. Tell your doctor if you have any sign of an infection such as fever, fatigue, cough, flu-like symptoms, or if you have open cuts or sores. You should be screened for tuberculosis (TB) before being given this drug. If you require a live vaccine, or if you are pregnant or nursing, you should discuss with your doctor whether you need to stop taking ustekinumab temporarily.

Common side effects include upper respiratory infections such as sinus infection and sore throat.

T-cell inhibitors

In psoriasis, T cells within the body’s immune system can be overactive. They cause skin cells to multiply seven to 12 times faster than normal. This overgrowth of skin cells leads to plaque formation. T-cell inhibitors, such as alefacept and efalizumab:

Prevent T-cells in the body’s immune system from becoming overactive
Lower the number of overactive T cells already in the body

Before you start taking a T-cell inhibitor and every two weeks during a course of treatment, your doctor should arrange to have the level of certain immune cells in your blood (CD4 T cells) checked. Depending on the results, your doctor will decide whether you need to postpone or stop the treatment.

Common side effects include a mild reaction involving pain, inflammation, bleeding or swelling at the site of injection and flu-like symptoms.

Phototherapy

Phototherapy is the use of ultraviolet (UV) light as a form of treatment. Several different forms of light treatment for psoriasis are available, including exposure to natural sunlight.

During phototherapy, psoriasis is exposed to ultraviolet light under medical supervision. Treatments are available at doctors’ offices, phototherapy clinics or even at home. The two most common kinds of light treatment used to treat moderate to severe psoriasis with thin plaques covering more than 3% of the skin are:

UVB (higher energy UV light)
UVA (lower energy light), which is always used in conjunction with a drug called psoralen, a treatment called PUVA

Both UVA and UVB rays are present in sunlight, and increasing your exposure to natural sunlight may benefit your psoriasis. Expose your psoriasis to noontime rays for five to 10 minutes daily, increasing your sun exposure by 30 seconds at a time if your skin reacts well. It may take several weeks of exposure to make a difference, and you must avoid overexposure to avoid sunburn. Some topical medications, such as tazarotene and tacrolimus, and other types of phototherapy can increase the risk of sunburn, skin cancer and premature aging. Sunscreen can protect skin without psoriasis, and sunglasses should be worn to shield your eyes from overexposure to sunlight.

Sun tips for psoriasis-free skin

Wear a broad-spectrum UVB and UVA sunscreen with SPF of at least 15.
Apply sunscreen daily if you spend more than 20 minutes under the sun.
Apply sunscreen from 15 to 30 minutes before going outside.
Reapply sunscreen every two hours and after active sports or swimming.

UVB phototherapy

UVB phototherapy is safe and effective but requires a significant time commitment. When UVB rays penetrate the skin, they slow the rapid growth of skin cells that occurs in psoriasis. During treatment, skin is exposed to a UVB light source for a set time over several weeks. Narrow-band UVB is more effective than broadband UVB, clearing the skin faster and giving longer periods between outbreaks. From 20 to 25 treatments, two to three times weekly, are usually needed.

UVB phototherapy is often combined with topical medications for better results. The Groeckerman Regimen (UVB plus coal tar) and the Ingram Regimen (UVB plus anthralin) are two examples.

Once psoriasis clears, treatment usually ends until plaques begin to reappear, but continuing UVB phototherapy for eight treatments per month may prolong the time between outbreaks.

Certain medications and herbal supplements can increase your sensitivity to light, so it is important to tell your doctor about any over-the-counter and prescription medications you take.

Overexposure to sunlight on treatment days may cause sunburn. UVB rays are known to cause skin cancer; a dermatologist should examine your skin from time to time to detect any early signs. Sunscreen can protect psoriasis-free skin from UVB overexposure.

Psoralen Ultraviolet-A Light Therapy (PUVA)

Psoralen is a light-sensitizing medication that enhances the effects of ultraviolet A (UVA) rays on psoriasis, hence the name PUVA. Like UVB phototherapy, PUVA slows the rapid growth of skin cells that occurs in psoriasis. PUVA can clear plaques in about 85% of people with moderate to severe psoriasis—and psoriasis-free time may last from a few months to longer than a year. It is slightly more effective than UVB phototherapy but has more risks and side effects, which is why it is not used as often as UVB phototherapy.

Psoralen can be taken orally or applied to the skin. Once high levels of psoralen are present in the skin, psoriasis is exposed to artificial UVA light under medical supervision.

An average of 25 PUVA treatments are needed before psoriasis clears. Severe psoriasis may take longer. One or two follow-up treatments per month may help to prevent outbreaks.

Oral psoralen may cause nausea, vomiting, headaches and sensitivity to UV light. Topical applications can concentrate higher levels of psoralen on tough-to-treat plaques.

Certain long-term risks are associated with PUVA, particularly skin cancer, freckling and premature aging of the skin. Because psoralen stays in the eye for up to 24 hours after it is swallowed, eyes must be protected from sunlight by UVA-blocking sunglasses—even indoors—to prevent cataracts.

Other Treatments

Other types of treatments for psoriasis are also available, including medications approved for other conditions, new and emerging therapies, and alternative and complementary therapies.

Medications approved for other conditions

Medications officially approved for treating other conditions/diseases have been tried in psoriasis with variable success. These include calcineurin inhibitors (e.g., tacrolimus, pimecrolimus) and other immunsuppressives (e.g., hydroxyurea, azathioprine, daclizumab, paclitaxel).

New and emerging therapies

Many new therapies for psoriasis have been developed recently, continually increasing the number of options for psoriasis patients. New medications and new approaches to treatment will continue to evolve over the coming years. Future research will help optimize different treatment combinations to help in situations where one therapy doesn’t work. With ever-expanding understanding of genetics, individually tailored therapies may even become common. Talk to your doctor about treatment options.

Alternative and complementary therapy

Up to 36% of U.S. adults have stated that they use some form of complementary or alternative medicine to treat their medical problems. Talk to your doctor about complementary therapies that may be right for you. Here is a brief overview of some of the most common:

Healthy diet

Many scientific studies have shown that a balanced, low-fat diet can improve your health and prevent many serious illnesses. Some doctors report that weight loss helps to improve their patients’ psoriasis, while weight gain triggers flares. Some people have found that certain foods trigger an outbreak. Eliminating these foods from their diet helps them to manage their psoriasis. However, reducing your intake of these foods will not necessarily help your psoriasis. These foods include:

Caffeine
Products that contain gluten, e.g., wheat flour
Alcohol
Sugar

Healthy eating can also improve your general well-being. Some experts believe that psoriasis may cause nutritional deficiencies in protein, folates (related to medication), water and calories. Correcting these deficiencies—if you have them—may help to improve your overall health.

Acupuncture

Eastern cultures have practised this form of holistic medicine for more than 2000 years. An acupuncturist inserts thin needles into specific body locations to balance life energy (Qi) and allow it to flow naturally throughout the body. Most people report that the procedure is relaxing and causes minimal discomfort. The number and length of acupuncture treatments vary from one patient to another, but multiple treatments over weeks or months are most common.

There is no scientific evidence to recommend the use of acupuncture for psoriasis, and its effectiveness has not been proven in clinical studies. People with psoriasis report mixed results—some say it helps; others report no benefit.

If you go this route, choose your practitioner carefully. Look for a trained, certified acupuncturist at the Acupuncture Foundation of Canada. Make sure that only sterile, single-use needles are used to avoid the risk of transmittable infectious diseases, such as hepatitis or HIV.

Herbal supplements

Herbal supplements of any kind can change how medications work. Before taking supplements, check with your doctor and do not exceed the doses that are recommended on the product’s label. No herbal supplement can cure psoriasis, but there is some solid scientific evidence that favours the use of some supplements over others.

• Milk thistle

Milk thistle may interfere with T-cell activation in the immune system. Overactive T cells are thought to cause psoriasis. There are no studies of its effectiveness in people with psoriasis, so no one knows if this herbal supplement will really work or how much of it to take. People who take antipsychotic medication or male hormones should not take milk thistle. This supplement may cause side effects and interfere with certain medications. Talk to your doctor before using it.

• Evening primrose oil

Two studies in patients with psoriatic arthritis have shown that oral supplements and topical oils that contain evening primrose have no beneficial effects on psoriasis. This supplement may cause side effects and interfere with certain medications. Pregnant women should not take evening primrose oil.

• Tea tree oil

First used for surgery and dentistry in the 1920s, tea tree oil is an extract of the Australia tea tree (Melaleuca alternifolia). With antibacterial and antiseptic properties, it was traditionally used to treat colds, headaches, toothaches, sore muscles and skin disorders. The oil is applied to the skin; it is poisonous when taken orally. There are no studies to show that it works, whether it is safe to use and how much to use to get benefits. A variety of products are available in pharmacies and other stores, including lotions, creams, soaps and shampoos. They contain various concentrations of tea tree oil, and some may irritate your skin. Some people get contact dermatitis from tea tree oil.

• Vitamins

The recommended daily doses of vitamin supplements have not improved psoriasis in scientific studies. Before taking larger doses – a dangerous practice that can harm your health – consult a registered dietitian, certified nutritionist or your doctor.

• Oregano oil

Oregano has antibacterial and antifungal properties, which may help to improve infections that are commonly associated with psoriasis. Oral or topical forms are available. Oregano may cause contact allergy when applied to the skin.

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