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Updated on January 9, 2025
Decades ago, psoriasis was considered a cosmetic issue but treatment for the condition has come a long way since then. Managing psoriasis typically depends on how severe it is. Primary care providers can begin treating mild psoriasis, but most people are treated by a specialist.
“The severity of the disease is going to guide the treatment,” says Alex Ortega-Loayza, MD, an associate professor of dermatology at Oregon Health & Science University in Portland. “If more than 10 percent of the body surface area is involved, we consider that severe psoriasis.” Less than three percent is mild psoriasis and three to 10 percent is moderate.
If you have joint pain too, you may have psoriatic arthritis. Approximately 30 percent of psoriasis patients will at some point develop psoriatic arthritis, usually within 10 years of being diagnosed with psoriasis. However, sometimes the two related conditions develop in the opposite order, with arthritis appearing first, and many don’t know they have psoriatic arthritis. A dermatologist treats psoriasis alone, and a rheumatologist treats psoriatic arthritis.
Psoriasis is an autoimmune condition, so some treatments work by suppressing your immune system. But immunosuppression increases the risk of infections, so it’s important to learn the risks and benefits of your treatment options. Here’s what you need to know about different treatment options for psoriasis and how to choose the best treatment for you.
Topical medications
For mild to moderate psoriasis, most treatment plans begin with topical medications in the form of creams, gels, sprays, shampoos, foams, solutions, and lotions. You might use several of these at once or combine them with other treatments.
Over-the-counter topical treatments include salicylic acid and coal tar but consult your healthcare provider (HCP) before using any. Fragrance-free moisturizers may help soothe your skin. Keep an eye out for the blue rectangular National Psoriasis Foundation seal of recognition on products, too. This seal highlights products that aren’t irritating to psoriatic skin.
Products with colloidal oatmeal or aloe vera can help with itching. Products containing capsaicin may help lower redness and inflammation. Some people find that shampoos with tea tree oil help with psoriasis on the scalp, but tea tree oil can cause allergic reactions, so take caution when trying it for the first time.
Prescription topical medications include steroidal creams, synthetic vitamin D creams, retinoids (vitamin A creams), and other non-steroidal treatments. Steroid creams, among the most common first-line treatments for psoriasis, reduce inflammation, redness, and swelling. But they’re typically not used long-term. Stopping them suddenly can also cause flare-ups. Calcineurin inhibitors can reduce inflammation and help when strong corticosteroids can’t be used. But just like steroids, they should not be used long-term.
Phototherapy
Light therapy, or phototherapy, targets the skin inflammation that causes your red, scaly, itchy flare-ups. It exposes the affected skin to ultraviolet rays. “It’s sometimes underused, but phototherapy can be very effective with severe psoriasis,” Ortega said.
There are several different ways to apply this therapy:
Natural sunlight in small doses might help your psoriasis symptoms. If you use sunlight, protect the rest of your skin from sunburn, and ask your HCP for a treatment plan, especially since some psoriasis medications make it more likely you’ll burn.
Artificial UVB rays can be delivered in quick doses by your healthcare provider (HCP). It’s good for treating psoriasis that wasn’t helped by topical treatments alone. It’s usually given in tandem with topical treatments. Don’t get discouraged when you start. Phototherapy may cause more itching, dry skin, or a rash. (Be sure to not use tanning beds. These mostly emit UVA light and increase the risk of skin cancer.)
Excimer laser therapy involves your HCP focusing a beam of UVB light directed at specific, localized patches of affected skin, but it may cause blisters or a rash.
Psoralen plus ultraviolet A (PUVA) is also sometimes known as photochemotherapy. UVA light can penetrate deeper layers of skin than UVB light. It’s paired with psoralen— a medication that increases the skin’s light sensitivity. It can help with more severe psoriasis, but it comes with its share of side effects, including burning, wrinkled skin, freckles, higher risk of skin cancer, and sensitivity to sunlight.
Systemic therapies
Systemic therapies are prescription drugs that work systemically, through the whole body. If topical treatments and phototherapy don’t control your psoriasis, it’s time to consider one of the traditional systemic therapies that have been around for a decade or more. Most of these are oral medications (some are given by injection) that usually need to be taken for longer periods of time before they start really relieving symptoms.
While some are approved specifically for psoriasis, others are considered “off-label,” meaning they are first and foremost meant to treat a different condition, but they have the side effect of being helpful for psoriasis.
Which therapy you try first will depend on your personal situation (such as whether you plan to get pregnant soon), your medical history (some aren’t recommended with certain pre-existing conditions), your insurance, your provider’s clinical experience and judgment, your specific symptoms, and your tolerance of side effects.
Most systemic therapies are immunosuppressive and can involve substantial side effects and risks that you should discuss with your HCP before you start taking them. Some drugs require ongoing monitoring and blood tests to ensure you don’t experience liver damage or other problems.
Not every drug is immunosuppressive, though. Acitretin is a systemic drug that does not suppress the immune system. And some more recent Food and Drug Administration (FDA)-approved long-term systemic oral medications are more targeted when they work with the immune system, selectively aiming for specific immune cell molecules, helping the body to scale down its overactive immune response. These drugs may also help relieve symptoms and damage from psoriatic arthritis.
Those who are pregnant, breastfeeding, allergic, have certain medical conditions, or taking certain medications cannot take some of these drugs, so make sure your HCP knows your medical history.
Biologics
Providers might prescribe you a biologic drug after trying the systemic ones or might skip straight to biologics, depending on your symptoms and what your insurance company allows. Biologics are proteins that block certain T cells or proteins in the immune system that cause skin or joint inflammation. Since biologics are made from living cells, your provider administers the drug as an injection or through an IV.
The FDA has approved about 16 biologics for psoriasis or psoriatic arthritis. Each has different side effects, but all carry a risk of infection and irritation at the injection site. Some involve rare, but serious risks such as blood or nervous system disorders or certain cancers.
A small percentage of people develop resistance to a biologic over time. “We don’t know why some people develop resistance and some people don’t,” Ortega said. “We can then switch biologics or add other medications that help control the disease as well.”
What’s right for you?
The right therapy for you depends on you and your symptoms and often involves trial and error. Your HCP considers your age, sex, occupation, resources, and likelihood of sticking with a treatment.
“It’s not only about the medication. It’s also about compliance,” Ortega said. Every treatment has side effects, so ask your HCP what to expect and say something if the side effects become unbearable.
“Three months is a good time frame to see if the patient is responding to treatment,” Ortega said, though you might stop a drug early because of side effects.
In his practice, Ortega sees 75 percent improvement in symptoms in about 60 to 70 percent of his patients. A small percentage are very difficult to treat, but more treatment options are always on the way. The National Psoriasis Foundation tracks all drugs in development for psoriasis and psoriatic arthritis.
“Treatments are getting better and better all the time,” Ortega said. “With personalized medicine,” Ortega said, “we’ll have the resources to find out which medication will work best with which patient.”
