Psoriasis - Treatment 

Treatments are determined by the type and severity of your psoriasis and the area of skin affected. Your GP 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 is available for psoriasis, but identifying which treatment is most effective can be difficult. Talk to your GP if you feel a treatment is not 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
• oral and injected medication: medicine that reduces the production of your skin cells, including biological treatments that target specific parts of the immune system

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.

Want to know more?

• PAPAA: psoriasis treatments
• What is a care plan?

Topical treatments are creams and ointments that you apply to the affected areas of skin. These initial treatments, also called first-line treatments, are used to treat mild to moderate psoriasis. They are all that some people need to control their condition.

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

Topical corticosteroids

Topical corticosteroids are commonly used to treat mild to moderate psoriasis in certain areas of the body, such as on the face or body folds (armpits and groin). The treatment works by reducing inflammation. This slows the production of skin cells and reduces the symptoms of itching.

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

Vitamin D analogues

Vitamin D analogue creams are one of the most common treatments for mild to moderate psoriasis. They work by slowing the production of skin cells. They also have an anti-inflammatory effect.

Vitamin D analogues are cleaner to use than other treatments. Types of vitamin D analogues include calcipotriol, calcitriol and tacalcitol. There are very few side effects, as long as you do not use more than the recommended amount.

Vitamin D analogues are often used in combination with topical corticosteroids.

Dithranol

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

It is typically used as a short-term treatment under hospital supervision as it stains everything it comes into contact with, including skin, clothes and bathroom fittings. It is 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).

Tazarotene

Tazarotene contains a chemical similar to vitamin A (retinoid), which slows the production of skin cells. It is used in the treatment of moderate plaque psoriasis. It is applied once a day.

The most common side effect of tazarotene is skin irritation around the area of application. Tazarotene cannot be used during pregnancy or if you are breastfeeding, as it could be harmful to the baby. It is not recommended for children or teenagers.

Coal tar

Coal tar is a thick, heavy oil and is probably the oldest treatment for psoriasis. How it works is not exactly known, but it can reduce scales, inflammation and itchiness. Coal tar can stain clothes and bedding and has a strong smell. It can be used in combination with phototherapy (see below).

Want to know more?

• The Psoriasis Association: first-line treatments for psoriasis
• The British Association of Dermatologists: topical treatments for psoriasis
• 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. You will usually need to be under the care of a dermatologist to receive phototherapy.

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 guttate or plaque psoriasis that has not responded to topical treatment. Each session only takes a few minutes but you may need to go to hospital three times a week for six to eight weeks.

Most machines used in the UK are TL01 narrow band UVB.

Psoralen plus ultraviolet A (PUVA)

For this treatment, you will 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 has not responded to other treatment. Side effects of the treatment include nausea, headaches, burning and itchiness. Long-term use of this treatment is not 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: ultraviolet treatment
• The British Association of Dermatologists: phototherapy
• PAPAA: psoriasis and phototherapy

You will normally only be prescribed tablets or injections if your psoriasis is severe and other treatments have not worked. These medications can be very effective in treating psoriasis but they all have potentially serious side effects.

All the oral and injected medicines for psoriasis have benefits and risks. Before starting oral medication, talk to your GP or dermatologist about your treatment options and any risks associated with them.

Methotrexate

Methotrexate decreases the production of skin cells and suppresses inflammation. It is taken as a tablet or by injection. It is used to treat pustular psoriasis, psoriatic erythroderma and extensive plaque psoriasis.

The drug can cause nausea and affects the production of blood cells. Long-term use can cause liver damage. People who have liver disease should not take methotrexate. Do not drink alcohol when taking methotrexate.

Methotrexate can be very harmful to a developing baby, so it is important that women use contraception and do not become pregnant while they take this drug and for three months after they stop.

Methotrexate can affect the development of sperm cells, so men should not father a child during treatment and for three weeks afterwards.

Acitretin

Acitretin is an oral retinoid that reduces the production of skin cells. It is used to treat severe psoriasis that has not responded to other treatments. It has a wide range of side effects, including dryness and cracking of the lips, dryness of the nasal passages, loss of hair and, in rarer cases, hepatitis.

Acitretin can be very harmful to a developing baby, so it is important that women use contraception and do not become pregnant while they take this drug and for two years after they stop taking it.

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

Hydroxycarbamide

Hydroxycarbamide is sometimes used for severe psoriasis. While it is not licensed for use in the treatment of psoriasis, some people find that it helps them. It works by slowing down the production of new cells. You will need to have a full blood test before you start taking hydroxycarbamide, as well as regular blood tests during treatment.

Hydroxycarbamide can be harmful to a developing baby, so it is important that women use contraception and do not become pregnant while they take this drug and for two months afterwards. Hydroxycarbamide can affect the development of sperm cells, so men should not father a child during treatment.

Biologic treatments (targeted therapy)

Biologic treatments reduce inflammation by targeting overactive cells in the immune system. Some biologics affect T-cells, while others target the chemicals that are released by T-cells. There are several types of biologic treatment. The National Institute for Health and Clinical Excellence (NICE) has assessed them and recommended when they should be used to treat adults.

Etanercept

Etanercept is used to treat severe plaque psoriasis that has not responded to other treatments (including methotrexate and ciclosporin) or if you cannot use other treatments. Etanercept is injected twice a week and you will be shown how to do this. If there is 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 is a risk of serious side effects including severe infection. If you had tuberculosis in the past, there is a risk that it may return. You will be monitored for side effects during your treatment.

Adalimumab

Adalimumab is used to treat severe plaque psoriasis that has not responded to other treatments (including methotrexate, ciclosporin and PUVA) or if you cannot use other treatments. Adalimumab is injected once every two weeks and you will be shown how to do this. If there is no improvement in your psoriasis after 16 weeks, the treatment will be stopped.

Adalimumab can be harmful to a developing baby, so it is important that women use contraception and do not 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 is a risk of serious side effects including severe infections. You will be monitored for side effects during your treatment.

Infliximab

Infliximab is used to treat very severe plaque psoriasis that has not responded to other treatments (including methotrexate, ciclosporin and PUVA) or if you cannot use other treatments. Infliximab is given as a drip (infusion) into your vein at the hospital. You will have three infusions in the first six weeks, then one infusion every eight weeks. If there is 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 is a risk of serious side effects including severe infections. You will be monitored for side effects during your treatment.

Ustekinumab

Ustekinumab is used to treat moderate to severe plaque psoriasis that has not responded to other treatments (including methotrexate, ciclosporin and PUVA) or if you cannot use other treatments. Ustekinumab is injected at the beginning of treatment, then again four weeks later. After this, injections are every 12 weeks. If there is 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 is a risk of serious side effects including severe infections. You will be monitored for side effects during your treatment.

Want to know more?

• The Psoriasis Association: systemic treatments
• The Psoriasis Association: biologic drugs for the treatment of psoriasis
• British Association of Dermatologists: etanercept
• British Association of Dermatologists: adalimumab
• British Association of Dermatologists: infliximab
• 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