How to Find the Right Psoriasis Treatment for Your Symptoms
Itchy, flaky psoriasis is never fun, but it can also sometimes be downright painful. Working with your derm to find the right treatment option is crucial, but with so many potential options to choose from—topicals, light therapy, biologics—you might feel overwhelmed by where to start.
What you should try first usually depends on the severity of your symptoms. That can be gauged by measuring the body surface area (BSA) that your symptoms affect or by scoring your symptoms on the psoriasis area and severity index (PASI), Saakshi Khattri, M.D ., a dermatologist and rheumatologist at Mount Sinai Hospital, tells SELF.
If 5 to 10 percent of your BSA is affected by psoriasis, you’re considered to have moderate-to-severe psoriasis, Dr. Khattri explains. Over 10 percent is considered severe psoriasis. (For reference, the size of your hand is roughly one percent of your BSA.)
But it’s not just how much of your body that’s covered by psoriasis that matters: The severity of your psoriasis also depends on how much it’s affecting your quality of life. If you just have psoriasis on your face, for instance, that might not cover that much of your body, but it could have more of an effect on your life because it’s highly visible, Dr. Khattri says.
When figuring out your treatment plan, your dermatologist will use these measures to score your psoriasis. Here are a few of the options out there that they might consider.
Topical treatments
Topicals are among the first-line treatments for psoriasis and can often manage mild-to-moderate cases of the condition. “Topical treatments for psoriasis include corticosteroids, synthetic vitamin D analogs, topical retinoids, coal tar, and calcineurin inhibitors,” Rachel E. Ward, M.D ., a dermatologist at Cleveland Clinic, tells SELF.
Topicals are a great option because they’re more targeted than other types of treatments. “The topical medications are used only on the areas of skin affected by psoriasis and avoided on normal skin,” Dr. Ward says, meaning that you shouldn’t experience widespread side effects.
In general, corticosteroids are a go-to for those with flare-ups who need results quickly. “These are fast-acting and have anti-inflammatory effects, and psoriasis tends to clear quickly with them,” Dr. Khattri. They’re also available in different potencies, with milder topical corticosteroids less likely to cause side effects.
However, corticosteroids can also thin the skin when used too frequently or used for a longer period of time—especially at higher potencies. So, these medications are best saved for an “acute situation” where you need fast relief, Dr. Khattri says.
There are some options, though, that may be a bit better for long-term use, including retinoids (vitamin A derivatives) and vitamin D analogues. Retinoids (like tazarotene) work by increasing the skin’s cell turnover process, but people who are pregnant need to avoid these medications. Vitamin D analogs (such as calcitriol) also work by regulating the production and development of skin cells.
Topical calcineurin inhibitors (such as tacrolimus ) are another option and are often used to treat psoriasis in more sensitive areas, like the face, Dr. Khattri. These can also be used in other areas where skin is thinner, like near the armpits, groin, and genitals. The most common side effect of these medications is an itching, burning feeling at the application site when you first start using it. But that should subside quickly as you adjust to the treatment.
Coal tar is another potential option that’s been used for nearly a century . It’s particularly useful in areas of the body that have hair , like your scalp, so you might find it over-the-counter in shampoos. But using it on other areas of the body can be messy.
Topical therapies (or even a combination of topical therapies) are usually a part of all psoriasis treatment plans at some point, whether you have mild or severe symptoms. “We often use these topical therapies in conjunction with light therapy or systemic medications for patients with moderate-to-severe disease,” Dr. Ward says. In particular, your doctor may recommend light therapy or another systemic treatment long-term and will add in a topical treatment during a flare-up.
Light therapy
For more widespread psoriasis, including moderate-to-severe cases, light therapy may be prescribed. “Phototherapy is a good option for patients who are unable to control their disease using topical therapies alone, or those wishing to avoid systemic medications,” Dr. Ward says. “Light treatments for psoriasis also act to decrease inflammation in the body, which, in turn, decreases itching and allows the skin to heal.”
There are several different types of phototherapy—including narrowband UVB, broadband UVB, targeted UVB [excimer laser or light], and UVA with psoralens (topical, oral, or bath)—and all of them involve exposing the skin to light. That usually happens in a small booth that's lined with fluorescent lights that give off a specific wavelength of light (sort of like an upright tanning booth). If only a small part of your body (like a hand or foot) needs to be exposed to the light, your doctor might recommend using another type of lamp that only shines on that part of your body. It's common to need treatments three times per week for a few months.
Once upon a time, doctors used broadband light—but it tends to cause sunburn and increase the risk for skin damage, “so we have moved away,” Dr. Khattri says. These days, light therapy involving narrowband UVB is most common. Targeted UVB therapy can be effective for “localized areas of psoriasis,” such as psoriasis affecting the hands and feet, nails, and scalp, Dr. Ward says. “The light therapy slows cell proliferation and has anti-inflammatory effects.”
The use of UVA therapy along with psoralens, a type of drug that increases the absorption of UVA waves, can also be effective, she explains. This combination of treatments (PUVA) can be used topically to manage localized psoriasis and for psoriasis affecting the hands and feet, Dr. Ward explains, and oral PUVA therapy can be used for more widespread disease.
It’s not common, but it is technically possible to experience localized redness and pain with light therapy, similar to a sunburn. “Oral PUVA therapy does have a potential to cause skin cancer with long-term use,” says Ward. “Phototherapy may not be the best option in patients with a history of melanoma, or many non-melanoma skin cancers.” It’s important to note, though: Light therapy is not the same as a tanning bed! It should not be used as such, or substituted with tanning bed use.
Light therapy is great if you have more surface area to treat than you can reasonably tackle with a cream—but it’s not great for people who don’t think they can stick to the treatment plan, which is time intensive.
Oral treatments and injectables
“If [a patient’s] BSA is more than 10 percent, your psoriasis is severe, and you cannot commit to phototherapy, then I do talk to them about oral and injectable treatments ,” Dr. Khattri says. They’re also used in patients who are dealing with psoriatic arthritis and who haven’t found topical or light therapy to be helpful, Dr. Ward explains. These systemic treatments are very effective, but they come with a higher risk for side effects and the need to be monitored closely by your derm.
Systemic therapies for psoriasis include oral therapy (such as methotrexate, cyclosporine, oral retinoids, and apremilast) as well as numerous injectable biologic and biosimilar medications. All of these medications target parts of the immune system, Dr. Ward says, but they work in different ways.
Biologic medications , which can be administered via IV or injection, “target more specific parts of the immune system,” Dr. Ward says, so they tend to have fewer side effects compared to oral medications, such as methotrexate.
That said, taking any medication that suppresses the immune system comes with the risk for potentially serious side effects and can affect your life moving forward. For instance, you will likely need consistent monitoring and may not be able to get certain vaccines. “Once you are talking about oral [medications] or biologics, it’s a long discussion to assess their risk and benefit,” Dr. Khattri. But, usually, if you are monitored by your doctor and have regular follow-ups, these systemic treatments can be effective options for those with severe psoriasis cases.
Remember, psoriasis treatment is individualized.
Psoriasis treatments are not one-size-fits-all. They are very individualistic, and also involve an increased focus on overall good wellness practices. Certain lifestyle changes can potentially make a difference, Dr. Ward says, which may include identifying and avoiding your triggers and finding healthy ways to manage stress.
It’s also important to remember that psoriasis is an autoimmune condition, and not simply “skin deep,” Dr. Ward says. It’s an inflammatory condition that can affect many parts of your body and increase your risk for cardiovascular issues, arthritis, and more. So it’s crucial to monitor these things with your primary care doctor as well as any specialists you may be working with.
The treatment of psoriasis often requires an entire team of physicians involving different specialties, including dermatologists for skin symptoms, rheumatologists if arthritis is involved, and primary care physicians to monitor overall health as you undertake new treatment. So, make sure you’re covering all your bases and seeing all appropriate doctors as you decide on a plan that’s right for you.
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