Psoriasis - Treatment 

Treatments are determined by the type and severity of your psoriasis and the area of skin affected. Your doctor will probably start with a mild treatment, such as topical creams (which are applied to the skin), and then move on to stronger treatments if necessary.

A wide range of treatments are available for psoriasis, but identifying which treatment is most effective can be difficult. Talk to your doctor if you feel a treatment isn't working or you have uncomfortable side effects.

Treatments fall into three categories:

• topical – creams and ointments that are applied to your skin
• phototherapy – your skin is exposed to certain types of ultraviolet light
• systemic – oral and injected medications that work throughout the entire body

Often, different types of treatment are used in combination.

Your treatment for psoriasis may need to be reviewed regularly. You may want to make a care plan (an agreement between you and your health professional) as this can help you manage your day-to-day health.

The various treatments for psoriasis are outlined below. You can also read a summary of the pros and cons of the treatments for psoriasis, allowing you to compare your treatment options.

Want to know more?

• National Institute for Health and Care Excellence (NICE): The assessment and management of psoriasis
• PAPAA: psoriasis treatments
• What is a care plan?

Topical treatments are usually the first treatments used for mild to moderate psoriasis. These are creams and ointments you apply to affected areas.

Some people find that topical treatments are all they need to control their condition, although it may take up to six weeks before there's a noticeable effect.

If you have scalp psoriasis, a combination of shampoo and ointment may be recommended.

Emollients

Emollients are moisturising treatments applied directly to the skin to reduce water loss and cover it with a protective film. If you have mild psoriasis, an emollient is probably the first treatment your GP will suggest.

The main benefit of emollients is to reduce itching and scaling. Some topical treatments are thought to work better on moisturised skin. It's important to wait at least half an hour before applying a topical treatment after an emollient.

Emollients are available as a wide variety of products and can be bought over the counter from a pharmacy or prescribed by your GP, nurse or health visitor.

Read more about emollients.

Steroid creams or ointments

Steroid creams or ointments (topical corticosteroids) are commonly used to treat mild to moderate psoriasis in most areas of the body. The treatment works by reducing inflammation. This slows the production of skin cells and reduces itching.

Topical corticosteroids range in strength from mild to very strong. Only use topical corticosteroids when recommended by your doctor. Stronger topical corticosteroids can be prescribed by your doctor and should only be used on small areas of skin or on particularly thick patches. Overusing topical corticosteroids can lead to skin thinning.

Vitamin D analogues

Vitamin D analogue creams are commonly used along with or instead of steroid creams for mild to moderate psoriasis affecting areas such as the limbs, trunk or scalp. They work by slowing the production of skin cells. They also have an anti-inflammatory effect.

Examples of vitamin D analogues are calcipotriol, calcitriol and tacalcitol. There are very few side effects, as long as you don't use more than the recommended amount.

Calcineurin inhibitors

Calcineurin inhibitors, such as tacrolimus and pimecrolimus, are ointments or creams that reduce the activity of the immune system and help to reduce inflammation. They're sometimes used to treat psoriasis affecting sensitive areas (such as the scalp, the genitals and folds in the skin) if steroid creams aren't effective.

These medications can cause skin irritation or a burning and itching sensation when they're started, but this usually improves within a week.

Coal tar

Coal tar is a thick, heavy oil and is probably the oldest treatment for psoriasis. How it works isn't exactly known, but it can reduce scales, inflammation and itchiness. It may be used to treat psoriasis affecting the limbs, trunk or scalp if other topical treatments aren't effective.

Coal tar can stain clothes and bedding, and has a strong smell. It can be used in combination with phototherapy (see below).

Dithranol

Dithranol has been used for over 50 years to treat psoriasis. It has been shown to be effective in suppressing the production of skin cells and has few side effects. However, it can burn if too concentrated.

It's typically used as a short-term treatment for psoriasis affecting the limbs or trunk under hospital supervision, as it stains everything it comes into contact with, including skin, clothes and bathroom fittings. It's applied to your skin (while wearing gloves) and left for 10 to 60 minutes before being washed off.

Dithranol can be used in combination with phototherapy (see below).

Want to know more?

• The Psoriasis Association: treatments from a GP
• PAPAA: emollients and psoriasis

Phototherapy uses natural and artificial light to treat psoriasis. Artificial light therapy can be given in hospitals and some specialist centres, usually under the care of a dermatologist. These treatments aren't the same as using a sunbed.

UVB phototherapy

Ultraviolet B (UVB) phototherapy uses a wavelength of light that is invisible to human eyes. The light slows down the production of skin cells and is an effective treatment for some types of psoriasis that haven't responded to topical treatments. Each session only takes a few minutes, but you may need to go to hospital two or three times a week for six to eight weeks.

Psoralen plus ultraviolet A (PUVA)

For this treatment, you'll first be given a tablet containing compounds called psoralens, or psoralen may be applied directly to the skin. This makes your skin more sensitive to light. Your skin is then exposed to a wavelength of light called ultraviolet A (UVA). This light penetrates your skin more deeply than ultraviolet B light.

This treatment may be used if you have severe psoriasis that hasn't responded to other treatment. Side effects of the treatment include nausea, headaches, burning and itchiness. You may need to wear special glasses for 24 hours after taking the tablet to prevent the development of cataracts. Long-term use of this treatment isn't encouraged, as it can increase your risk of developing skin cancer.

Combination light therapy

Combining phototherapy with other treatments often increases its effectiveness. Some doctors use UVB phototherapy in combination with coal tar, as the coal tar makes the skin more receptive to light. Combining UVB phototherapy with dithranol cream may also be effective (this is known as Ingram treatment).

Want to know more?

• The Psoriasis Association: treatments for a dermatologist
• PAPAA: psoriasis and phototherapy

If your psoriasis is severe or other treatments haven't worked, you may be prescribed systemic treatments by a specialist. Systemic treatments are treatments that work throughout the entire body.

These medications can be very effective in treating psoriasis, but they all have potentially serious side effects. All the systemic treatments for psoriasis have benefits and risks. Before starting treatment, talk to your doctor about your treatment options and any risks associated with them.

There are two main types of systemic treatment, called non-biological (usually given as tablets or capsules) and biological (usually given as injections). These are described in more detail below.

Non-biological medications

Methotrexate

Methotrexate can help to control psoriasis by slowing down the production of skin cells and suppressing inflammation. It's usually taken once a week.

Methotrexate can cause nausea and may affect the production of blood cells. Long-term use can cause liver damage. People who have liver disease shouldn't take methotrexate, and you shouldn't drink alcohol when taking it.

Methotrexate can be very harmful to a developing baby, so it's important that women use contraception and don't become pregnant while they take this drug and for three months after they stop. Methotrexate can also affect the development of sperm cells, so men shouldn't father a child during treatment and for three weeks afterwards.

Ciclosporin

Ciclosporin is a medicine that suppresses your immune system (immunosuppressant). It was originally used to prevent transplant rejection, but has proved effective in treating all types of psoriasis. It's usually taken daily.

Ciclosporin increases your chances of kidney disease and high blood pressure, which will need to be monitored.

Acitretin

Acitretin is an oral retinoid that reduces the production of skin cells. It's used to treat severe psoriasis that hasn't responded to other non-biological systemic treatments. It's usually taken daily.

Acitretin has a wide range of side effects, including dryness and cracking of the lips, dryness of the nasal passages and, in rarer cases, hepatitis.

Acitretin can be very harmful to a developing baby, so it's important that women use contraception and don't become pregnant while they take this drug, and for two years after they stop taking it. However, it's safe for a man taking acitretin to father a baby.

Biological treatments

Biological treatments reduce inflammation by targeting overactive cells in the immune system. These treatments are usually used if you have severe psoriasis that hasn't responded to other treatments, or if you can't use other treatments.

Etanercept

Etanercept is injected twice a week and you'll be shown how to do this. If there's no improvement in your psoriasis after 12 weeks, the treatment will be stopped.

The main side effect of etanercept is a rash where the injection is given. However, as etanercept affects the whole immune system, there's a risk of serious side effects, including severe infection. If you had tuberculosis in the past, there's a risk it may return. You'll be monitored for side effects during your treatment.

Adalimumab

Adalimumab is injected once every two weeks and you'll be shown how to do this. If there's no improvement in your psoriasis after 16 weeks, the treatment will be stopped.

Adalimumab can be harmful to a developing baby, so it's important that women use contraception and don't become pregnant while they take this drug, and for five months after the treatment finishes.

The main side effects of adalimumab include headaches, a rash at the injection site and nausea. However, as adalimumab affects the whole immune system, there's a risk of serious side effects, including severe infections. You'll be monitored for side effects during your treatment.

Infliximab

Infliximab is given as a drip (infusion) into your vein at the hospital. You'll have three infusions in the first six weeks, then one infusion every eight weeks. If there's no improvement in your psoriasis after 10 weeks, the treatment will be stopped.

The main side effect of infliximab is a headache. However, as infliximab affects the whole immune system, there's a risk of serious side effects, including severe infections. You'll be monitored for side effects during your treatment.

Ustekinumab

Ustekinumab is injected at the beginning of treatment, then again four weeks later. After this, injections are every 12 weeks. If there's no improvement in your psoriasis after 16 weeks, the treatment will be stopped.

The main side effects of ustekinumab are a throat infection and a rash at the injection site. However, as ustekinumab affects the whole immune system, there's a risk of serious side effects, including severe infections. You'll be monitored for side effects during your treatment.

Newer drugs

Ixekizumab and secukinumab are fairly new biological treatments. They're recommended as possible treatments for severe psoriasis when this hasn't improved with other treatments, or when other treatments aren't suitable.

Want to know more?

• NICE guidance on etanercept and efalizumab for the treatment of psoriasis (efalizumab has been withdrawn from use because of safety concerns and NICE has suspended its guidance on this drug)
• NICE guidance on adalimumab for psoriasis
• NICE guidance on infliximab for psoriasis
• NICE guidance on ustekinumab for the treatment of adults with moderate to severe psoriasis
• NICE guidance on ixekizumab for treating moderate to severe plaque psoriasis
• NICE guidelines on secukinumab for treating moderate to severe plaque psoriasis