Psoriasis Treatment

For people with mild to moderate psoriasis, treatment often begins with topical medications—creams, ointments, or lotions applied directly to the affected skin. These are usually the first line of defense and can work well when psoriasis is limited to a few areas.

• Corticosteroids are the most prescribed topical treatment. They reduce inflammation and slow down the production of skin cells. These medications vary in strength, and weaker versions are used on sensitive areas like the face, while stronger formulations may be used on tougher skin like elbows or knees.
• Vitamin D analogs such as calcipotriene help slow skin cell growth and can be used with corticosteroids. These are especially helpful for plaque psoriasis.
• Topical retinoids, which normalize DNA activity in skin cells and reduce inflammation.
• Salicylic acid, another topical agent, helps soften and remove thick scales allowing topical medications to better penetrate.
• Coal tar preparations and moisturizers can also help relieve itching and scaling.
• Calcineurin inhibitors like tacrolimus and pimecrolimus are used off-label for psoriasis affecting sensitive areas such as the face and skin folds. They are non-steroidal and help reduce inflammation.

Phototherapy involves controlled exposure of the skin to ultraviolet (UV) light and is often used for moderate to severe psoriasis that does not respond well to topical treatments.

• UVB phototherapy uses artificial UVB light to slow the growth of affected skin cells. It can be administered as narrowband or broadband UVB.

• Excimer laser therapy targets specific patches of psoriasis with a concentrated beam of UVB light. This is often used for localized psoriasis on areas like the hands, feet, elbows, and knees.

Systemic therapies affect the entire body and are typically reserved for moderate to severe psoriasis or psoriatic arthritis. These medications are taken by mouth or injection.

Traditional systemic medications include:

• Methotrexate, which suppresses the immune system and can reduce the rapid skin cell turnover seen in psoriasis.
• Cyclosporine, another immunosuppressant, provides fast relief but is usually used short-term due to potential kidney and blood pressure side effects.
• Acitretin, an oral retinoid, helps slow skin cell growth but is not recommended for women who are pregnant or may become pregnant due to birth defect risks.

Biologics are a newer class of medications that target specific parts of the immune system that are overactive in people with psoriasis. They are usually reserved for moderate to severe cases or for those with psoriatic arthritis, which causes joint pain and swelling along with skin symptoms.

Biologics are given as injections or intravenous infusions, and they include drugs such as adalimumab, etanercept, ustekinumab, secukinumab, and ixekizumab. These medications block certain immune system proteins—like TNF-alpha or interleukins—that contribute to the inflammation and rapid skin cell turnover seen in psoriasis. Biologics can be very effective and often improve symptoms significantly, sometimes even clearing the skin completely. However, they may increase the risk of infection and are typically more expensive than other treatments.

Small molecule drugs, such as apremilast (Otezla) and deucravacitinib (Sotyktu), are taken orally and work by modifying inflammatory pathways. These drugs may be appropriate for patients who are not candidates for biologics.

Many people with psoriasis benefit from a combination of treatments. The goal of combination therapy is to improve results while minimizing side effects by using lower doses of each treatment.