21 Tips and Tricks for Treating Psoriasis
Although there is no cure for psoriasis, oral and topical medications are an invaluable tool for many people in managing the disease. Topicals—which are applied directly to the skin—can reduce itching and inflammation, improve the skin’s appearance, and normalize abnormal cell production, which is thought to be one of the causes of psoriasis.
First line of defense
If your condition is isolated to a few areas, topicals are the first line of defense, says Steven Feldman, MD, PhD, professor of dermatology at the Wake Forest University School of Medicine in Winston-Salem, N.C.
"I divide patients into two groups: Those with a few spots where I use topicals, and those with so many spots that you can’t possibly put topicals on all of them." For those with psoriasis that covers many areas,
Your dermatologist may also decide to use topicals in combination with other medications. Try to make applying them part of your daily routine, and make sure to apply them only to the part of the body directed by your doctor to avoid unwanted side effects.
A key to treating psoriasis is keeping your skin moisturized every day, and especially in dry or cold weather. Patients recommend ointments such as Vaseline and lotions to minimize itching and redness; finding the right product is a process of trial and error. Whatever you choose, slather the affected parts of your body immediately after a bath or shower.
How this age-old remedy helps psoriasis sufferers remains something of a mystery. "We have no idea how it works," says Robert E. Kalb, MD, clinical associate professor of dermatology at the University at Buffalo School of Medicine in Buffalo, N.Y.
Doctors presume that it reduces the overproduction of skin cells. The upside to tar products is that they don’t cause side effects. The downside is that they’re smelly and messy, and can stain fabric.
"Steroids are the mainstay of topical treatments," says Dr. Kalb. Also known as topical corticosteroids, topical steroids are one of the most popular topical solutions and come in a wide range of potencies, from mild formulas available over the counter to heavy-duty prescriptions.
How steroids work
Steroids decrease inflammation, relieve itching, and slow the development of new psoriasis patches. Although effective, aggressive topical steroids can cause skin thinning (which can lead to stretch marks), so many dermatologists recommend using them only for a short period of time. "The challenge is to maintain the benefits without using them too much," says Dr. Kalb.
Vitamin D analogues
Synthetic versions of vitamin D, these medications control the overproduction of skin cells, decreasing scaling and itching. They are not as fast acting as topical steroid products, but the upside is that they don’t have the skin-thinning side effects of steroids.
Many doctors use vitamin D analogues as a complement to steroids; once the psoriasis is under control with steroids, Dr. Kalb often switches his patients to a popular vitamin D derivative called Dovonex (also known by its generic name calcipotriene), or uses it in conjunction with lower doses of steroids. Another product called Taclonex combines calcipotriene with a steroid.
Vitamin A derivatives
Vitamin A derivatives such as Tazorac (also known as tazarotene) slow down the growth of skin cells and reduce inflammation. They are commonly used on areas such as the face, scalp, and nails, although they sometimes can cause skin irritation.
This treatment, often used in conjunction with other topical remedies, reduces inflammation and helps remove scales that appear on psoriasis patches. Salicylic acid is available both over the counter and by prescription in lotions, soaps, shampoos, and other forms.
Oral medications have been used for decades to treat psoriasis. In recent years patients with moderate to severe psoriasis have increasingly switched to newer biologic medications, which are injected, but oral medications (also known as “systemics”) are still an important and commonly used treatment for psoriasis.
"The good news is that psoriasis is manageable, manageable now to the point that for the majority of patients we can completely clear the skin of all skin lesions and do so fairly safely. Just a few years ago, we didn't have such great options," says Steven Feldman, MD, PhD, professor of dermatology at the Wake Forest University School of Medicine in Winston-Salem, N.C. "Treatments are now more effective, safer and easier to use than ever."
What it is: Methotrexate belongs to a class of drugs known as antimetabolites, and it works by interfering with the overproduction of skin cells that causes psoriatic plaques to develop. Methotrexate is usually taken once a week in a single dose of up to 30 mg, although it is sometimes broken up into three smaller doses spread out over a 24-hour period.
More on Methotrexate
Studies have shown that methotrexate is effective in 70% to 80% of psoriasis patients. In a 2003 study of oral medications published in the New England Journal of Medicine, 60% of the patients who received methotrexate experienced partial remission; of those patients, 65% saw near-complete remission. Patients usually start to see results after two to three months.
Cyclosporine is an immunosuppressant drug that fights psoriasis by suppressing the faulty immune cells that signal skin cells to grow too quickly. It is usually taken once a day as a capsule or in liquid form.
Acitretin is a retinoid, a type of synthetic vitamin A. Usually known by its brand name, Soriatane, acitretin is taken as a once-a-day pill and is the only oral systemic not available as a generic. It is often combined with phototherapy.
Originally used to treat psoriatic and rheumatoid arthritis, Humira was approved for psoriasis in 2008. In long-term controlled trials, between 55% and 70% of the patients taking Humira experienced a 75% reduction in their plaques (a common measure of clearance known as “PASI 75”.
Administered via IV in a dermatologist’s office every eight weeks, Remicade is perhaps the most powerful biologic. The two trials that have studied the long-term efficacy of Remicade report PASI 75 response rates of around 80%.
One of the earliest biologics approved for psoriasis, Enbrel is considered to be relatively safe and well tolerated, although it is less powerful than Humira. Studies report PASI 75 rates ranging from about 45% to 60%.
Amevive is the only biologic designed to be used intermittently, in 12-week intervals. Although one study reported PASI 75 rates of nearly 30% at 12 weeks and more than 50% at 60 weeks, the evidence suggests that Amevive may be the least effective biologic in the long term.
Stelara, which was approved by the U.S. Food and Drug Administration (FDA) in September 2009, is the newest biologic. It is injected just once every three months (after a pair of initial doses four weeks apart). And because it isn't a T-cell modulator or TNF inhibitor, it provides an alternative for patients who haven't responded to other biologics. In clinical trials, Stelara has achieved PASI 75 response rates between roughly 65% and 80%.