Psoriasis Medications

Since psoriasis is incurable, the selection of treatment plans must consider the long-term outlook. Treatment options depend on the extent and severity as well as the emotional response to the disease. They include topical agents (drugs applied to the skin), phototherapy (controlled exposure to ultraviolet light), and systemic agents (orally, intravenously, or percutaneously administered agents). All of these treatments may be used alone or in combination with one another. Psoriasis in children younger than 15 years of age is rare; therefore, the following review is confined to adult options.

Topical agents: Medications applied directly to the psoriatic skin lesions are the safest approaches to treatment but are only practical if treating localized disease. The most popular topical treatments are corticosteroids (in vehicles such as foams, creams, gels, liquids, sprays, or ointments), calcium modulators, coal tar extracts, and anthralin. There isn't one topical drug that is best for all people with psoriasis. Because each drug has adverse effects or limited efficacy, it may be necessary to rotate them. Sometimes topical preparations are combined together. For example, keratolytics (substances used to break down scales or excess skin cells) are often added to these preparations to enhance their penetration into the skin. Some preparations should never be mixed together because they interfere with each other. For example, salicylic acid inactivates calcipotriene cream or ointment. On the other hand, drugs such as anthralin (tree bark extract) may require the addition of salicylic acid to work effectively.

Phototherapy (light therapy): Ultraviolet (UVL) light, a portion of the solar spectrum with wavelengths between 290-400 nm, can have beneficial effects on psoriatic skin presumably by altering certain immune functions. Disease that is considered too extensive to be treated by topical approaches, that is usually greater than 5%-10% of the total body surface area, is an appropriate indication for this sort of treatment. Resistance to conventional topical treatment is another indication for light therapy. Although normal sunlight contains these wavelengths, self-exposure to sunlight must be done in under controlled conditions to minimize burns. In a physician's office, control of the amount of light energy administered to each patient is essential. Medical light sources use special wavelengths of light and timers to assure the correct dosage of light. Sunlamps and tanning booths are not acceptable substitutes for medical light sources. Ultraviolet light from any source is known to produce skin cancer, but this side effect is minimized when the light is appropriately administered in a physician's office.

• UV-B: Ultraviolet B (UV-B) light is used to treat psoriasis. UV-B is light with wavelengths of 290-320 nanometers (nm), shorter than the range of visible light. (Visible light ranges from 400-700 nm.) UV-B therapy may usually be combined with one or more topical treatments. UV-B phototherapy is effective for treating moderate-to-severe plaque psoriasis. The major drawbacks of this therapy are the time commitment required for treatments and the accessibility of UV-B equipment. With long-term use, there is a risk of skin cancer, just as there is from natural sunlight.
  • The Goeckerman regimen uses coal tar followed by UV-B exposure and has been shown to produce improvement in more than 80% of patients. The odor of coal tar limits its popularity. The treatments involve twice-a-day light exposure plus daily application of the tar preparation for two to four weeks. This is no small commitment and either requires hospitalization or using a psoriasis day-care treatment center.
  • In the Ingram method, the drug anthralin is applied to the skin after a tar bath and UV-B treatment.
  • UV-B therapy can be combined with the topical application of corticosteroids, calcipotriene (Dovonex), tazarotene (Tazorac), or creams or ointments that soothe and soften the skin.
  • Narrow-band UVB light sources produce wavelengths of ultraviolet light at about 313 nm, which seems to be particularly effective for controlling psoriatic plaques while minimizing side effects. It rivals PUVA in its efficacy.
• PUVA: PUVA is the therapy that combines a psoralen-containing oral medication with ultraviolet A (UV-A) light therapy. Psoralens make the skin more sensitive to long-wave UVA (320-400 nm). Methoxsalen (Oxsoralen) is a psoralen that is taken by mouth before UV-A light therapy. More than 85% of patients report relief of disease symptoms with 20-30 treatments. Therapy is usually given two to three times per week on an outpatient basis, with maintenance treatments every two to four weeks to maintain remission. Adverse effects of PUVA therapy include nausea, itching, and burning. Long-term complications include increased risks of sensitivity to the sun, sunburn, skin cancer, skin aging and cataracts. Protective glasses must be worn during and after treatment to prevent cataracts. PUVA therapy is not used for children younger than 12 years of age.

Systemic agents (drugs taken orally or administered by injection or intravenous infusion): These drugs are often started after both topical treatment and phototherapy have been carefully considered. Certain systemic agents are also very effective in controlling psoriatic arthritis. People whose disease is disabling because of physical, psychological, social, or economic reasons may also be considered for systemic treatment.

Corticosteroids

Clobetasol (Temovate), triamcinolone (Aristocort), fluocinolone (Synalar), and betamethasone (Diprolene) are examples of commonly prescribed corticosteroids.

• How corticosteroids work: Corticosteroids decrease skin inflammation and itching.
• Who should not use these medications: Individuals with corticosteroid allergy or skin infections should not use corticosteroids.
• Use: Apply a thin film to affected skin areas. These creams or ointments are usually applied two times a day, but dosage depends on severity of the psoriasis.
• Drug or food interactions: No interactions have been reported with topical use.
• Adverse effects: Corticosteroids may cause adverse effects to the body if used over large areas. They can also cause local thinning of the skin. Do not use for long periods of time. It is best not to put bandages over the treated skin unless directed by the physician because too much of the medicine may be absorbed into the body.

Creams and Ointments Related to Vitamin D

Calcipotriene (Dovonex) is a relative of vitamin D-3 that is used to treat moderate psoriasis.

• How vitamin D medications work: Calcipotriene slows the production of excess skin cells.
• Who should not use these medications: Individuals with the following conditions should not take calcipotriene:
  • Allergy to calcipotriene cream
  • Elevated calcium levels in the blood
  • Vitamin D toxicity
• Use: Apply to affected skin area two times a day. This medication is available as a cream, ointment, or solution.
• Drug or food interactions: Topical salicylic acid inactivates calcipotriene. Do not use creams or ointments containing these medicines at the same time.
• Adverse effects: Do not use this medicine on the face, around the eyes, or inside the nose or mouth. Do not use more than 100 grams per week (one large tube of cream or ointment). This agent may cause skin irritation and is impractical and expensive for widespread application. It is frequently supplied as a combination drug with a topical steroid (Taclonex) to diminish its irritation potential.

Tar-Containing Preparations

• Coal tar (DHS Tar, Doak Tar, Theraplex T) is a complex mixture of thousands of different substances extracted from the coal during the carbonization process. Coal tar is applied topically and is available as shampoo, bath oil, ointment, cream, gel, lotion, ointment, paste, and other types of preparations. Sometimes coal tar is combined with UV-B light therapy.
• How coal tar works: The tar decreases itching and slows the production of excess skin cells.
• Who should not use these medications: Individuals with the following conditions should not use tar-containing preparations:
  • Tar allergy
  • Recent severe inflammation, including pustular psoriasis
  • Patches of psoriasis that are bleeding or oozing
• Use: Apply coal tar preparations daily for severe psoriasis. Apply two times per week for mild psoriasis. Rub the medicine on the skin or scalp and rinse thoroughly. Repeat, leave on for five minutes, and then rinse thoroughly.
• Drug or food interactions: No interactions have been reported.
• Adverse effects: Avoid contact with eyes, inside the nose or mouth, or open wounds. Stop using if the skin becomes more irritated or if symptoms are not reduced. Coal tar tends to stain clothing and linens and can have an undesirable odor. This medicine may cause the skin to be more sensitive to the sun than normal. Coal tar may also cause inflammation of hair follicles.

Tree Bark Extracts

Anthralin (Dithranol, Anthra-Derm, Drithocreme) is a synthetic form of a tree bark extract that is considered to be one of the most effective topical antipsoriatic agents available. However, it can cause skin irritation and staining of clothing and skin.

• How tree bark extract works: This medicine slows the production of excess skin cells.
• Who should not use these medications: Individuals with anthralin allergy or recent or excessively swollen patches should not use anthralin.
• Use: Apply a small amount of the cream, ointment, or paste to the patches on the skin. On the scalp, remove scales and rub into affected areas. Avoid the forehead, eyes, and any skin that does not have patches. Do not apply excessive quantities. Short applications of a high concentration for only 20 minutes, followed by washing with soap and water can be used to minimize skin irritation.
• Drug or food interactions: Anthralin is combined with salicylic acid in preparations used for psoriasis treatment.
• Adverse effects: Anthralin stains clothing or linens purple or brown. Use with caution if the individual has kidney disease. Care must be taken to apply this medication only to psoriasis patches and not to surrounding normal skin. Anthralin may cause skin discoloration (increased pigment) and may burn or irritate skin. Do not use on the face, neck, skin folds (back of knees or elbows), or genitals. Avoid contact with the eyes. Do not use on excessively irritated patches. This medication should only be used if the patient can comply with instructions for use.

Topical Retinoids

Tazarotene (Tazorac) is a topical retinoid that is available as a gel or cream. This medicine is sometimes combined with corticosteroids to decrease skin irritation when used alone and to increase effectiveness. Tazarotene is particularly useful for psoriasis of the scalp.

• How topical retinoids work: They reduce the size of psoriasis patches and the redness of the skin.
• Who should not use these medications: Individuals with the following conditions should not use topical retinoids:
  • Allergy to retinoids
  • Pregnancy (Note: A pregnant woman should not use or take a retinoid medicine.)
  • Breastfeeding
• Use: Apply a thin film to the affected skin every day or as instructed. Dry skin before using this medicine. Irritation may occur when applied to damp skin. Wash hands after application. Do not cover with a bandage.
• Drug or food interactions: Cosmetics or soap products that dry or irritate the skin may worsen the irritation and dry skin when used with a topical retinoid.
• Adverse effects: Do not use this medicine on the face, around the eyes, or inside the nose or mouth. Do not use on open wounds or sunburned skin. This medicine often is irritating and can cause burning or stinging. Sensitivity to the sun may occur. If skin irritation or pain increase, contact a doctor.

Retinoids

Acitretin (Soriatane) is used for severe psoriasis.

• How retinoids work: Retinoids are used to control psoriasis and reduce the redness of the skin. They can be used in combination with medically controlled ultraviolet phototherapy to minimize the dose of each.
• Who should not use these medications: Individuals who are allergic to retinoids, are pregnant, or are breastfeeding should not take retinoids.
• Use: Acitretin is in a capsule. It is usually taken once a day by mouth with food. Therapy is continued until plaques have decreased.
• Drug or food interactions: Acitretin increases methotrexate toxicity when both are used together. This medicine can interfere with oral contraceptives ("minipill"). Do not use alcohol while taking acitretin and for two months after stopping the medicine. Alcohol causes the drug to convert to a long-acting form and could prolong the risk of birth defects.
• Adverse effects: Women of childbearing age must use effective birth control measures. Birth control must be continued for at least three years after the woman stops taking acitretin because the drug stays in the body for a very long time and will hurt unborn babies. Caution must be used if the individual has kidney or liver problems. Contact the doctor immediately if one develops a rash or skin or vision changes.

Psoralens

Methoxsalen (Oxsoralen-Ultra) and trioxsalen (Trisoralen) are commonly prescribed psoralens. Psoralens are a class of drugs that make the skin more sensitive to light and the sun. Psoralens are used with ultraviolet light therapy. This therapy, called PUVA, uses a psoralen with ultraviolet A (UV-A) light to treat psoriasis when it covers a large area of the skin or is severe. More than 85% of patients report relief of disease symptoms with 20-30 treatments.

• How psoralens work: Psoralens have no effect unless combined with ultraviolet light therapy. They are used with the light therapy to slow skin-cell overproduction.
• Who should not use psoralens: Individuals with the following conditions should not take psoralens:
  • Psoralen allergy
  • History of skin cancer
  • Photosensitivity diseases such as porphyria, lupus erythematosus, xeroderma pigmentosum, or albinism
  • Inability to tolerate prolonged standing or heat, for example, in those with heart disease
  • Pregnancy
  • Children younger than 12 years of age
• Use: Psoralens are taken by mouth 45-60 minutes prior to UVA exposure. Occasionally, psoralens have been applied to the skin in creams, lotions, or bath soaks. This requires close medical monitoring due to the propensity to produce burns. Treatments frequency should not be shorter than 48 hours.
• Drug or food interactions: Other photosensitizing drugs, such as phenothiazines, bacteriostatic soaps, sulfonamides, tetracyclines, thiazides, or even perfumes may increase the skin's sensitivity to the sun or may cause other problems. Before taking psoralens, let the doctor know if any other medicine are being taken.
• Adverse effects: A doctor experienced with PUVA therapy should supervise the use of these medicines. Severe burns can occur from sunlight or the ultraviolet light while taking psoralens. These drugs cause sensitivity to sunlight and increase the risk of sunburn, skin cancer, and cataracts. After each treatment, avoid going out in the sun for at least 24 hours. Cover up with clothing and use sun block if the skin will be exposed to the sun. A certain type of sunglasses are recommended to protect the eyes after treatments. Treatment usually causes reddening of the skin for 24-48 hours. However, contact the doctor if severe redness, blisters, fever, or peeling occurs.

Antimetabolites, Immunosuppressives, and Biologic Response Modifiers

These agents are potent drugs given by mouth or injection. They block inflammation and have effects on the immune system. The effect on skin is probably secondary to the effect on white blood cells.

Adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), ustekinumab (Stelara), secukinumab (Cosentyx), ixekizumab (Taltz), methotrexate (Rheumatrex), cyclosporine (Sandimmune, Neoral), and apremilast (Otezla) are in this group of systemic drugs. They may be prescribed for moderate to severe psoriasis.

How these drugs work: These medications can block inflammation. They are used to treat people with severe disabling psoriasis who have not responded to or tolerated other treatments.

• The Biologics: Adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), ustekinumab (Stelara), secukinumab (Cosentyx), and ixekizumab (Taltz) are proteins, also called "biologics," that are produced by microorganisms and work on the immune system by blocking certain specific chemical messengers of the inflammatory pathway. For example, tumor necrosis factor (TNF) is involved in inflammation and is blocked by three of these medications. They all are expensive.
  • Who should not use biologics: Individuals with an allergy to these medications and those with a serious infection should not use these drugs.
  • Use:
    • Adalimumab is self-administered as an injection every two weeks.
    • Etanercept is given as an injection two times per week. The drug can be injected at home. Rotate the site of injection (thigh, upper arm, abdomen). Do not inject into bruised, hard, or tender skin.
    • Infliximab must be administered in the doctor's office. It is an intravenous (IV, given into the vein) infusion that is administered slowly over two hours. Initially, three doses are administered within a six-week period, and then the drug is administered every eight weeks for maintenance.
    • Ustekinumab, secukinumab, and ixekizumab are administered by injection at longer intervals after a short induction phase.
  • Drug or food interactions: The safety and efficacy of these medications in patients receiving other immunosuppressive drugs have not been evaluated. Patients receiving these medications may receive concurrent vaccinations, except for live vaccines, such as the MMR and yellow fever vaccines.
  • Adverse effects: Serious infections may develop and the therapy should be discontinued if they occur. Possible adverse effects include injection-site pain, redness and swelling at injection site, and headaches. Rarely, lupus-like symptoms, lymphoma, reactivation of tuberculosis, and heart failure have been reported (treatment is stopped if symptoms develop).
• Methotrexate (Rheumatrex): This drug is used to treat plaque psoriasis and psoriatic arthritis. However, it is sometimes not effective.
  • Who should not use methotrexate: Women who are planning to get pregnant or who are pregnant should not take this drug. Men must not take this drug if there is a possibility of getting their partners pregnant because it can go into the sperm. Additionally, people with the following conditions should not use methotrexate:
    • Methotrexate allergy
    • Alcoholism
    • Liver or kidney problems
    • Immune deficiency syndromes
    • Low blood cell levels
  • Use: Methotrexate is taken by mouth (tablet) or as an injection once per week.
  • Drug or food interactions: Tell the doctor if any nonsteroidal anti-inflammatory drugs (Motrin, Advil, Aleve, aspirin) are being taken because these may act with methotrexate and cause adverse symptoms.
  • Adverse effects: The doctor will order blood tests to check blood cell count and liver and kidney function on a regular basis. Methotrexate may cause toxic effects on the blood, kidneys, liver, gastrointestinal tract, lungs, and nervous system. A liver biopsy may be needed to check the health of the liver, especially after prolonged use.
• Cyclosporine (Sandimmune, Neoral)
  • Who should not use cyclosporine: Individuals with the following conditions or treatments should not take cyclosporine:
    • Cyclosporine allergy
    • Uncontrolled hypertension
    • Kidney problems
    • Cancer
    • PUVA (UV-A light therapy combined with medications that make the skin sensitive to light) or UV-B light therapy (may increase cancer risk)
  • Use: Cyclosporine is taken by mouth once a day.
  • Drug or food interactions: Many drug interactions exist. Carbamazepine (Tegretol), phenytoin (Dilantin), isoniazid, rifampin (Rifadin), and phenobarbital may decrease cyclosporine blood concentrations; azithromycin (Zithromax), itraconazole (Sporanox, Onmel), nicardipine, ketoconazole (Nizoral, Xolegel, Extina), fluconazole (Diflucan), erythromycin (E-Mycin, Eryc, Ery-Tab, Pce, Pediazole, Ilosone), verapamil (Calan, Verelan, Verelan PM, Isoptin, Isoptin SR, Covera-HS), grapefruit juice, diltiazem (Cardizem, Dilacor, Tiazac), aminoglycosides, acyclovir (Zovirax), amphotericin B, and clarithromycin (Biaxin) may increase toxicity; acute kidney failure, muscle breakdown and muscle pain may worsen when cyclosporine is taken concurrently with lovastatin (Mevacor, Altoprev).
  • Adverse effects: The doctor will order tests to check kidney function, may monitor levels of cyclosporine in the blood, or may order other blood tests while an individual is on this medicine. Cyclosporine may increase the risk of infection or lymphoma, and it may cause kidney damage producing high blood pressure.
• Apremilast (Otezla)
  • This drug works by inhibiting an enzyme that plays a role in the inflammatory process.
  • Who should not use apremilast: Anyone with a known sensitivity to the drug
  • Use: This is a newly developed oral drug for the treatment of psoriasis and psoriatic arthritis. Its efficacy is touted as being similar to the biologic response modifiers. Major side effects seem to be gastrointestinal so that it is recommended to start with a low dose and gradually increase it to the full therapeutic amount over about a week to avoid intolerable GI symptoms. No special laboratory tests for monitoring are required.
  • Adverse events: Major adverse events are gastrointestinal upset and subsequent weight loss.

National Psoriasis Foundation
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Portland, OR 97223-7195
800-723-9166
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