Psoriasis Treatments

Psoriasis Treatments

Psoriasis is a chronic, non-contagious autoimmune disease that causes skin cells to build up much faster than normal. This rapid turnover results in thick, scaly, and inflamed patches on the skin. Although commonly appearing as red, pink, or purple areas with silvery-white scales, the appearance and severity of psoriasis varies from person to person. Some people experience only small patches, while others have more widespread involvement. While psoriasis can be itchy or dry, symptoms can range from mild to severe, and it is sometimes entirely calm.

This condition affects both men and women and may start at any age, though it often appears between ages 15-to-35. The exact cause isn’t known, but it is believed to be a combination of genetic, immune system, and environmental factors.

What Are the Common Symptoms of Psoriasis?

  • Raised, inflamed patches of skin
  • Silvery-white scales on red or purplish base
  • Dry or cracked skin that may bleed
  • Itching, burning, or soreness
  • Thickened or ridged nails
  • Painful, swollen joints (psoriatic arthritis)

Symptoms often come and go in flares and may be triggered by stress, infections, medications, weather changes, or skin injuries.

Psoriatic Arthritis

Psoriasis doesn’t just affect the skin. About 30% of people with psoriasis develop psoriatic arthritis (PsA), an inflammatory joint condition. PsA can affect any joint in the body and may mimic other types of inflammatory arthritis. Symptoms often include:

  • Joint pain or stiffness
  • Swelling and redness around joints
  • Fatigue and morning stiffness

Early detection and management of joint involvement are crucial. If you’re noticing joint pain along with your skin symptoms, talk to your dermatologist or rheumatologist right away. Skin or joint symptoms can develop first, but often the joint disease is not recognized until after the skin rash develops.  

Psoriasis is also linked with several systemic health conditions, including:

  • Cardiovascular disease
  • Diabetes
  • Liver disease
  • Metabolic syndrome
  • Inflammatory bowel disease (IBD)
  • Depression and anxiety

Types of Psoriasis

There are several forms of psoriasis, each with different symptoms and affected areas:

  • Plaque Psoriasis: Most common form of psoriasis. Features raised patches of skin with silvery-white scale, usually found on the elbows, knees, scalp, and lower back.
  • Nail Psoriasis: Affects fingernails and toenails, causing discoloration, pitting, thickening, or separation from the nail bed. Nail involvement may indicate a higher risk for psoriatic arthritis.
  • Guttate Psoriasis: Appears as small, red, teardrop-shaped spots on the trunk and limbs. It often develops after a strep throat infection.
  • Inverse Psoriasis: Develops in skin folds, such as in the armpits, under the arms, under the breasts, or in the groin. The skin appears smooth, shiny, and red rather than scaly due to constant moisture and friction.
  • Pustular Psoriasis: Features white, non-infectious pustules surrounded by red skin. It may be localized to the palms and soles or more widespread on the trunk and body.
  • Palmoplantar Psoriasis: Affects the palms of the hands and soles of the feet. It can cause thickening, cracking, and pain that interferes with walking and/or manual work.
  • Erythrodermic Psoriasis: A rare, severe form that causes widespread redness, scaling, and peeling of the skin. It can lead to life-threatening complications like dehydration, infection, and organ failure.

Treatment Options for Psoriasis

While there is no cure for psoriasis, a variety of treatments can help control symptoms and improve quality of life. Treatment plans are personalized based on the severity, type of psoriasis, and whether joints are involved.

Topical Treatment Options

  1. Local Corticosteroids (Steroids)
  • How Corticosteroids Work:
    • Anti-inflammatory action: Corticosteroids block the release of inflammatory chemicals (cytokines) in the skin, reducing redness and swelling.
    • Immune modulation: They suppress overactive immune cells responsible for triggering psoriasis flares.
    • Slow cell growth: By normalizing skin cell turnover, steroids help plaques become thinner and less scaly.
  • Types of Corticosteroids for Psoriasis
    • Topical Corticosteroids
      • Creams, Ointments, Gels, Foams, and Lotions: Available in different potencies, from mild (e.g. hydrocortisone) to very potent (e.g. clobetasol propionate).
      • Usage: Applied directly to plaques.
      • Best for: Localized patches on arms, legs, trunk, and scalp.
    • Intralesional Corticosteroids
      • Injected directly into thick plaques: Useful for stubborn, plaque-type lesions, especially on scalp, elbows, knees, and nails.
      • Frequency: Typically administered in clinic every 4–6 weeks. 
  • Benefits of Corticosteroid Treatment
    • Rapid reduction in redness, scaling, and itching
    • Improvement in quality of life by controlling flares
    • Flexible options
    • Inexpensive
  • Potential Side Effects & Safety Considerations
    • While generally safe when used correctly, corticosteroids can cause side effects, especially if overused or used incorrectly.
    • Skin thinning (atrophy):
      • More common with high-potency steroids and/or prolonged use.
    • Stretch marks (striae):
      • May develop in areas where the skin becomes very thin.
    • Steroid rosacea or perioral dermatitis:
      • Facial use can trigger acne-like eruptions.
    • Systemic absorption:
      • If used over a large body surface area or under occlusion, topical steroids can enter the bloodstream and potentially cause systemic side effects (see “Systemic Corticosteroids” section below).
  • Tips for Safe Use
    • Always follow your provider’s instructions: Use the correct potency and duration.
    • Use the lowest effective potency:
      • Start with a mild to moderate steroid and only escalate if needed.
    • Limit duration:
      • Typically, no longer than 2–4 weeks on a given area without re-evaluation.
    • Alternate therapies:
      • For maintenance, use non-steroidal options (vitamin D analogs, topical calcineurin inhibitors, etc.).
    • Protect sensitive areas:
      • Avoid potent steroids on the face, underarms, and groin unless specifically directed by your provider.
    • Monitor for side effects:
      • Report irritation, thinning skin, or new symptoms to your dermatologist right away.
  1. Vitamin D Analogs
  • How Vitamin D Analogs Work:
    • Normalization of Cell Turnover: Slow down the rapid proliferation of keratinocytes that cause thick, scaly plaques.
    • Anti-Inflammatory Effects: By modulating immune cell activity, Vitamin D Analogs reduce local inflammation and pro-inflammatory cytokines.
    • Promotion of Skin Barrier Health: These agents can improve epidermal differentiation, strengthening the skin’s natural barrier and reducing trans-epidermal water loss.
  • Common Vitamin D Analogs
    • Calcipotriene (Calcitrene, Dovonex)
      • Available as cream, ointment, solution, and foam.
      • Typically applied twice daily to affected areas.
    • Tacalcitol (Curatoderm)
      • Not currently available in USA.  Approved in Europe and Japan.
      • Applied once or twice daily, depending on concentration and physician guidance.
  • Benefits of Vitamin D Analog Treatment
    • Plaque Improvement:
      • Noticeable reduction in plaque thickness, scaling, and redness within 4–8 weeks of consistent use.
    • Favorable Safety Profile:
      • Minimal risk of skin atrophy compared to potent corticosteroids; suitable for long-term maintenance therapy.
    • Versatility:
      • Can be used on most body areas, including face and intertriginous regions.
    • Combination Potential:
      • Often paired with topical corticosteroids or other non-steroidal therapies to enhance efficacy and minimize side effects.
  • Potential Side Effects & Safety Considerations
    • Skin Irritation:
      • Mild burning, itching, or stinging at application sites – usually temporary and resolves with continued use.
    • Hypercalcemia (rare):
      • Excessive absorption can raise calcium levels; avoid applying to large surface areas or under occlusion without medical supervision.
    • Photosensitivity:
      • May increase sun sensitivity; use broad-spectrum sunscreen and limit direct UV exposure when using these products.
    • Application Limits:
      • Do not exceed recommended total body surface area (usually no more than 100 g/week of calcipotriene).
  • Tips for Safe and Effective Use
    • Follow Application Instructions:
      • Apply a thin layer to clean, dry skin once or twice daily, as directed by your dermatologist.
    • Use Sparingly on Sensitive Areas:
      • If treating face, groin, or underarms, choose lower-strength formulations and monitor for irritation.
    • Pair With Moisturizer:
      • Allow the analog to absorb fully (10–15 minutes) before applying a fragrance-free moisturizer to support barrier repair.
    • Rotate Therapies:
      • For long-term control, consider alternating weeks of vitamin D analogs with other topical agents to minimize side effects and maintain response.
    • Avoid Excessive Sun:
      • Wear protective clothing and sunscreen, as these medications can heighten sensitivity to UV light.
  1. Aryl Hydrocarbon Receptor (AHR) Agonists
  • How AHR Agonists Work:
    • Receptor Activation: AHR agonists bind to the AHR protein in keratinocytes and immune cells, triggering gene expression changes that modulate both innate and adaptive immune responses.
    • Anti-Inflammatory Effects: Activation of AHR down-regulates pivotal cytokines (such as IL-17 and IL-23), curbing the inflammation that drives plaque formation.
    • Antioxidant Support: AHR signaling enhances production of enzymes that neutralize reactive oxygen species, protecting skin cells from oxidative damage.
    • Barrier Restoration: Upregulated expression of barrier-forming proteins improves skin integrity and reduces water loss, alleviating dryness and scaling.
  • Common AHR Agonists
    • Tapinarof (Vtama Cream)
      • Tapinarof 1% cream is the only FDA-approved topical AHR agonist for plaque psoriasis (as of 2025).
      • Dosing: Apply a thin layer once daily to all affected areas.
      • Formulation: lightweight cream that absorbs quickly, making it suitable for use on the face, scalp, and body.
  • Benefits of AHR Agonists
    • Non-Steroidal:
      • Eliminates risks of skin thinning, stretch marks, and rebound flares associated with corticosteroids.
    • Once-Daily Application:
      • Simplifies treatment schedules and improves adherence.
    • Versatile Use:
      • Safe for sensitive areas (face, intertriginous zones) under physician guidance.
    • Complementary Therapy:
      • Can be combined with vitamin D analogs or systemic treatments to enhance overall disease control.
  • Potential Side Effects & Safety Considerations
    • Local Irritation:
      • Mild burning, itching, or redness may occur at the application site; these symptoms often resolve with continued use.
    • Folliculitis:
      • In rare cases, small bumps around hair follicles can develop; report persistent changes to your provider.
    • Contact Dermatitis:
      • Although uncommon, allergic reactions may occur. Discontinue use if pronounced redness, swelling, or weeping develops.
  • Tips for Safe and Effective Use
    • Apply to Clean, Dry Skin:
      • Gently cleanse and pat dry before applying a thin layer of Tapinarof once daily, ideally at a consistent time.
    • Avoid Occlusion:
      • Do not cover treated areas with bandages or wraps unless specifically instructed.
    • Rotate Therapies for Maintenance:
      • After achieving clearance, discuss with your dermatologist whether to continue Tapinarof alone or alternate with other non-steroidal topical medications to sustain results.
  1. Topical Retinoids
  • How Retinoids Work:
    • Regulation of Keratinocyte Differentiation: Retinoids binds to nuclear retinoic acid receptors (RARs), promoting normalized maturation of skin cells and preventing the excessive buildup of scale.
    • Anti-Proliferative Effects: By modulating gene expression, retinoids slow down hyperproliferation of keratinocytes, thinning plaques over time.
    • Anti-Inflammatory Action: Retinoids inhibit inflammatory cytokines (e.g., IL-6, IL-8) in the skin, reducing redness and alleviating itch.
  • Common Topical Retinoids
    • Tazarotene (Tazorac)
      • Formulations:
        • Cream: 0.05% and 0.1%
        • Gel: 0.05% and 0.1%
      • Dosing: Apply a thin film once or twice daily, to fully dried, affected areas.
      • Usually begin with a lower strength to assess tolerance before escalating.
    • While there are many other topical retinoids on the market, they are not typically used for psoriasis.
  • Benefits of Topical Retinoid Therapy
    • Plaque Improvement:
      • Gradual but sustained reduction in thickness, scaling, and erythema, with visible improvement often by 6–8 weeks.
    • Maintenance Potential:
      • Once lesions clear, intermittent “pulse” use (e.g., 2–3 times/week) helps prevent relapse.
    • Steroid-Sparing:
      • Can be combined with topical corticosteroids to boost clearance while minimizing amount of steroid needed.
    • Versatility:
      • Suitable for most body sites; however, avoid applying on very sensitive skin (face, intertriginous areas) unless directed.
  • Potential Side Effects & Safety Considerations
    • Local Irritation:
      • Commonly causes dryness, peeling, redness, and burning, especially during the first 2–4 weeks.
    • Photosensitivity:
      • Increases sun sensitivity; strict sun protection is required.
    • Teratogenicity:
      • Contraindicated in pregnancy. Women of childbearing potential must use effective contraception during treatment and for 1 month after discontinuation.
    • Avoid on Broken Skin:
      • Do not apply to open wounds or eczematous areas to prevent excessive irritation.
  • Tips for Safe and Effective Use
    • Start Slowly:
      • Apply every other night for the first week, then increase to nightly as tolerated.  In dry regions of the country (like Lakewood, Colorado!), apply every third night for a full month before increasing if using on sensitive areas.
    • Moisturize Liberally: Apply a gentle, fragrance-free moisturizer on top of the retinoid to combat dryness.
    • Sun Protection:
      • Use broad-spectrum SPF 30+ daily, wear protective clothing, and limit sun exposure.
  1. Calcineurin Inhibitors
  • How Calcineurin Inhibitors Work:
    • Enzyme Inhibition: Bind to intracellular proteins FKBP-12 (tacrolimus) or macrophilin-12 (pimecrolimus), forming complexes that inhibit calcineurin phosphatase and block calcineurin.
    • T-Cell Suppression: By blocking calcineurin, they prevent dephosphorylation and nuclear translocation of NFAT transcription factors, reducing IL-2 and other cytokines central to psoriatic inflammation.
    • Barrier Support: Unlike steroids, they do not impair collagen synthesis or thin the dermis, helping maintain skin integrity.
  • Common Calcineurin Inhibitors
    • Tacrolimus (Protopic)
      • Strengths: 0.03% and 0.1% ointments
      • Dosing: Apply a thin layer twice daily.
    • Pimecrolimus (Elidel)
      • Strength: 1% cream
      • Dosing: Apply a thin layer twice daily; particularly useful for facial or intertriginous lesions.
  • Usage is Off-Label for Psoriasis
    • While not FDA-approved specifically for psoriasis, many dermatologists prescribe these agents for psoriasis rashes, especially on the face, eyelids, groin, and other thin-skinned areas to minimize topical steroid side effects.
  • Benefits of Calcineurin Inhibitors
    • Steroid-Sparing:
      • Ideal for maintenance on sensitive areas where long-term steroids risk atrophy, striae, or telangiectasias.
    • Non-Atrophogenic:
      • Preserve epidermal and dermal thickness, even with prolonged use.
    • Minimal Systemic Absorption:
      • Low risk of systemic immunosuppression when used as directed.
    • Complementary Therapy
      • Can be combined with vitamin D analogs, steroids, or other treatments to enhance clearance.  Using as a maintenance medication helps to minimize the cumulative steroid burden.
  • Potential Side Effects & Safety Considerations
    • Local Irritation:
      • Transient burning, stinging, or pruritus (itching) in the first days of therapy.
    • Flushing or sensitivity to heat, spicy foods, or alcohol
  • Tips for Safe and Effective Use
    • Apply to Clean, Dry Skin: 
    • Use a Thin Film:
      • Less is more – excess product increases irritation without boosting efficacy.
    • Consistent Schedule:
      • Twice-daily dosing, at roughly 12-hour intervals, optimizes suppression of T-cell activity.
  1. Salicylic Acid
  • How Salicylic Acid Works:
    • Keratolysis: Disrupts intercellular connections in the stratum corneum, allowing thick scales to slough off more easily.
    • Enhanced Penetration: By removing excess scale, salicylic acid increases the effectiveness of concurrent treatments (e.g., corticosteroids, vitamin D analogs).
    • Mild Anti-Inflammatory Action: At higher concentrations, it can modestly reduce inflammation and redness in treated areas.
  • Common Formulations & Concentrations
    • Creams and Ointments: 2%–6% salicylic acid, applied once or twice daily to localized plaques.
    • Shampoos and Solutions: 2% salicylic acid, ideal for scalp psoriasis; use 2–3 times per week.
    • Medicated Pads or Gels: Convenient for targeted application on hands, elbows, or knees.
  • Benefits of Salicylic Acid Therapy
    • Rapid Scale Reduction:
      • Noticeable softening and thinning of plaques within days of consistent use.
    • Synergistic Use:
      • Prepares the skin for other topicals, improving overall clearance rates.
    • Versatility:
      • Available in multiple vehicles for body, scalp, and nail treatment.
    • Over-the-Counter Access:
      • Lower concentrations can be purchased without a prescription for mild flares.
  • Potential Side Effects & Safety Considerations
    • Skin Irritation:
      • Burning, stinging, or redness, especially if used too frequently or under occlusion.
    • Dryness and Peeling:
      • Can over-exfoliate if applied to healthy skin; start with lower concentrations if you have sensitive skin.
    • Salicylate Absorption:
      • Rare systemic effects (tinnitus, headache) when applied over large areas at high strengths; avoid widespread occlusion.
    • Avoid Open Wounds:
      • Do not use on broken or eczematous skin to prevent excessive irritation or systemic uptake.
  • Tips for Safe and Effective Use
    • Cleanse and dry the treatment area before application.
    • Begin with a lower strength (2%–3%) once daily; increase frequency or concentration based on tolerance.
    • Apply sparingly to plaques only. Avoid healthy skin margins.
    • On the scalp, rinse the head after use to minimize residue and scalp dryness.
    • Apply salicylic acid first, wait 15–20 minutes, then layer other prescribed topicals.
    • Moisturize: Follow with a gentle, fragrance-free moisturizer to soothe any irritation.
  1. Coal Tar
  • How Coal Tar Works:
    • Antiproliferative Action: Coal tar suppresses excessive keratinocyte proliferation, helping plaques become thinner and less scaly.
    • Anti-Inflammatory Effects: Inhibits DNA synthesis in inflammatory cells, reducing redness and itch.
    • Keratolytic Support: At higher concentrations, tar softens and loosens thick scales, enhancing exfoliation.
  • Common Formulations & Strengths
    • Creams and Ointments: 0.5%–10% coal tar; applied once or twice daily to affected areas.
    • Shampoos and Solutions: 0.5%–5% concentrations for scalp psoriasis; use 2–3 times per week.
    • Bath Oils and Gels: Added to lukewarm bath water (10–20 mL per bath) to cover large body surface areas.
    • Foams and Gels: Modern, cosmetically elegant vehicles that rub into skin nicely and feel soothing.
  • Benefits of Coal Tar Therapy
    • Broad Application Area:
      • Effective on the scalp, elbows, knees, and torso; available in multiple vehicles.
    • Cost-Effective:
      • Often less expensive than many prescription topicals.
    • Dual-Action:
      • Provides both anti-inflammatory and mild keratolytic effects in one product.
    • Complementary Therapy:
      • Can be combined with UVB phototherapy (Goeckerman regimen) or layered under corticosteroids/vitamin D analogs.
  • Potential Side Effects & Safety Considerations
    • Skin Irritation:
      • Burning, stinging, or contact dermatitis, especially at higher concentrations.
    • Folliculitis:
      • Pustules around hair follicles may occur with occlusive use.
    • Odor and Staining:
      • Characteristic tar smell and potential yellow-brown staining of clothes and bedding; this is more common with older formulations.
  • Tips for Safe and Effective Use
    • Patch Test First:
      • Apply a small amount to a discrete area for 3–5 days to check for allergic sensitivity.
    • Begin with Lower Strength:
      • Start at 0.5%–2% once daily; increase concentration or frequency based on tolerance.
    • Combine with Emollients:
      • Apply moisturizer before or after tar treatment to reduce dryness.
    • Timing with Phototherapy:
      • If using in a Goeckerman regimen, follow your clinic’s specific protocol for coal tar application and UV exposure.
    • Protect Clothing and Linens:
      • Wear old garments, use dark towels, and sleep with old sheets to avoid staining nice clothes, bedding, and towels.
  1. Topical Phosphodiesterase-4 (PDE4) Inhibitors
  • How PDE4 Inhibitors Work:
    • Enzyme Blockade: PDE4 inhibitors prevent the breakdown of cAMP (messenger molecule) in skin cells, leading to elevated cAMP levels.
    • Cytokine Modulation: Increased cAMP downregulates pro-inflammatory mediators such as TNF-α, IL-17, and IL-23, central drivers of psoriatic inflammation.
    • Barrier Support: Reduced inflammation promotes normalization of keratinocyte behavior and supports restoration of the skin barrier.
  • Common PDE4 Inhibitors:
    • Roflumilast (Zoryve)
      • Formulations: 0.3% cream and foam
      • Dosing: Apply a thin layer once daily to all affected areas.
      • Indication: Approved for mild-to-moderate plaque psoriasis, including intertriginous areas.
    • Crisaborole (Eucrisa)
      • Formulation: 2% ointment
      • Indication: FDA-approved for eczema; use in psoriasis patients is off-label
  • Benefits of PDE4 Inhibitors
    • Non-Steroidal:
      • Eliminates risks of skin atrophy, stretch marks, and rebound flares associated with prolonged corticosteroid use.
    • Once-Daily Application:
      • Simplifies treatment adherence compared to twice-daily regimens.
    • Well-Tolerated:
      • Minimal systemic absorption with a favorable safety profile for long-term use.
    • Complementary Therapy:
      • Can be used alongside other topicals (e.g., vitamin D analogs) or systemic agents for enhanced disease control.
  • Potential Side Effects & Safety Considerations
    • Local Irritation:
      • Mild burning, stinging, or itching at the application site, often transient and improves with continued use.
    • Contact Dermatitis:
      • Rare allergic reactions; discontinue if you develop pronounced redness, swelling, or weeping.
    • Photosensitivity:
      • Use broad-spectrum sunscreen and protective clothing to minimize UV sensitivity.
  • Tips for Safe and Effective Use
    • Use the Right Amount:
      • A thin film is sufficient. Applying more does not increase efficacy and may heighten irritation.
    • Apply Consistently:
      • Choose a regular time each day to build a routine and maximize therapeutic effect.
    • Pair with Emollients:
      • Apply a fragrance-free moisturizer on top of medication to maintain hydration.

Phototherapy Treatment Options

Phototherapy uses controlled doses of ultraviolet (UV) light to slow skin cell turnover, reduce inflammation, and clear psoriatic plaques. Administered in a dermatology clinic or with home-based devices under close supervision, light therapy can be a highly effective, non-invasive option for moderate to extensive psoriasis.  

  • How Phototherapy Works
    • Immune Modulation: UV light alters local immune cell activity, reducing the release of pro-inflammatory cytokines that drive plaque formation.
    • Inhibition of Keratinocyte Proliferation: UV exposure slows the rapid growth of skin cells, allowing plaques to thin and scale to shed naturally.
    • Induction of Apoptosis: Damaged or overactive skin cells undergo programmed cell death, leading to incremental plaque clearing over multiple sessions.
  • Common Types of Phototherapy
    • Narrowband UVB (NB-UVB)
      • Delivers a precise 311 nm wavelength of UVB light; regarded as the gold standard for light treatment of plaque psoriasis due to its balance of efficacy and safety.
    • Broadband UVB (BB-UVB)
      • Emits a wider range of UVB wavelengths; less commonly used but still effective for some patients.
    • PUVA (Psoralen + UVA)
      • Involves taking a light-sensitizing medication (psoralen) before UVA exposure; typically reserved for more severe or treatment-resistant disease.
    • Excimer Laser
      • Delivers an intense, focused beam of 308 nm UVB light that targets individual plaques; ideal for localized lesions and avoiding exposing healthy skin to unnecessary UV radiation.
  • Benefits of Phototherapy
    • Non-Steroidal:
      • Eliminates risks associated with long-term topical steroid use, such as skin thinning.
    • Whole-Body Treatment:
      • Effective for widespread psoriasis that is impractical to treat with topicals alone.
    • Predictable Dosing:
      • Medical phototherapy devices deliver measured UV doses that minimize the chance of burning and allow for optimal clearance.  
    • Maintenance Potential:
      • Once clearance is achieved, “touch-up” sessions can sustain remission without daily treatments.
  • Potential Side Effects & Safety Considerations
    • Sunburn-Type Reactions:
      • Redness, itching, or blistering can occur if doses are too high or intervals too frequent.
    • Premature Photoaging:
      • Cumulative UV exposure may contribute to fine lines, pigmentation changes, and loss of elasticity over time.
    • Skin Cancer Risk:
      • Although more limited with NB-UVB, all phototherapy (especially long-term PUVA) carries a higher risk of non-melanoma skin cancers; risk mitigation strategies are critical.  
    • Eye Protection:
      • UV light can damage the eyes; goggles or eye shields must be worn during every session.
  • Tips for Safe and Effective Use
    • Adhere to Your Schedule:
      • Most regimens involve 2–3 sessions per week, with at least 48 hours between treatments.
    • Monitor Your Skin:
      • Report any unexpected redness or blistering immediately so your dermatologist can adjust dosing.
    • Protect Unaffected Areas:
      • Use barrier creams or coverings on sensitive sites (face, genitals) if not treating those areas.
    • Maintain Moisture:
      • Apply a gentle, fragrance-free moisturizer after each session to soothe treated skin.
    • Limit Additional UV Exposure:
      • Avoid tanning beds (always) and prolonged sun exposure; always wear broad-spectrum sunscreen on untreated areas.

Oral Treatment Options

  1. Systemic Corticosteroids (Steroids)
  • How Corticosteroids Work:
    • Anti-inflammatory action: Corticosteroids block the release of inflammatory chemicals (cytokines) in the skin, reducing redness and swelling.
    • Immune modulation: They suppress overactive immune cells responsible for triggering psoriasis flares.
    • Slow cell growth: By normalizing skin cell turnover, steroids help plaques become thinner and less scaly.
  • Benefits of Systemic Corticosteroid Treatment
    • Reserved for severe flares or psoriatic arthritis not responsive to other systemic agents.
    • Rapid reduction in redness, scaling, and itching
    • Improvement in quality of life by controlling flares
    • Inexpensive
  • Common Oral Corticosteroids
    • Prednisone
    • Prednisolone
    • Dexamethasone (Decadron)
    • Methylprednisolone (Medrol)
  • Potential Side Effects & Safety Considerations
    • While generally safe when used correctly, corticosteroids can cause side effects, especially if not taken as prescribed.
    • Short courses or abrupt discontinuation can cause a severe rebound flare of psoriasis.
    • Mood changes (irritable, euphoric, restless, fidgety).
    • High blood sugar.
    • Flushing.
    • High blood pressure.
    • With prolonged use: bone density loss, glaucoma, muscle weakness, and weight gain.
  • Tips for Safe Use
    • Always follow your provider’s instructions: Use the correct dose and duration.
    • Never abruptly stop oral steroids.  
    • Consider non-steroid alternative treatments.
    • Monitor for side effects: manage blood sugar, hypertension, etc. while taking.
  1. Oral Immunosuppressant Medications:
  • How Oral Immunosuppressants Work
    • Broad Immune Suppression: Inhibit activated T-cells and other immune pathways that drive inflammation and keratinocyte overgrowth.
    • Cytokine Reduction: Down-regulation of pro-inflammatory mediators (e.g., TNF-α, IL-17, IL-23) leads to decreased plaque formation and joint symptoms.
    • Slowed Cell Turnover: By dampening immune signals, these drugs normalize keratinocyte proliferation and reduce scaling.
  • Common Oral Immunosuppressants
    • Methotrexate (Trexall)
      • Mechanism: Folate antagonist that inhibits DNA synthesis in rapidly dividing immune cells.
      • Dosing: 7.5–25 mg once weekly, often with daily folic acid supplementation.
    • Cyclosporine (Neoral, Sandimmune)
      • Mechanism: Calcineurin inhibitor that blocks T-cell activation.
      • Dosing: 2.5–5 mg/kg/day in divided doses; typically used short-term use (≤12 months).
    • Azathioprine (Imuran)
      • Mechanism: Purine analog that impairs lymphocyte proliferation.
      • Dosing: 1–3 mg/kg/day, adjusted by thiopurine methyltransferase (TPMT) activity.
    • Mycophenolate Mofetil (CellCept) (off-label)
      • Mechanism: Inhibits inosine monophosphate dehydrogenase, reducing lymphocyte growth.
      • Dosing: 1–3 g/day in divided doses.
  • Benefits of Oral Immunosuppressants
    • Rapid and sustained plaque clearance for extensive body involvement.
    • Psoriatic arthritis control, improving joint pain and stiffness.
    • Flexibility to combine with topicals, phototherapy, or biologics for enhanced effect.
    • Once-daily or weekly dosing simplifies adherence compared to multiple daily topicals.
  • Potential Side Effects & Safety Considerations
    • Methotrexate: Hepatotoxicity, bone marrow suppression, pulmonary fibrosis, teratogenicity.
    • Cyclosporine: Nephrotoxicity, hypertension, gum hypertrophy, hirsutism.
    • Azathioprine: Bone marrow suppression, hepatotoxicity, gastrointestinal upset.
    • Mycophenolate: Diarrhea, leukopenia, increased infection risk.
    • General Risks: Increased susceptibility to infections, potential malignancy risk with long-term use.
  • Monitoring & Precautions
    • Baseline Labs:
      • CBC with differential, liver function tests, renal panel, blood pressure.
      • Pregnancy test, if applicable.
    • Ongoing Monitoring (not inclusive; labs are tailored to each patient and their medical situation):
      • Methotrexate: CBC and LFTs every 4–8 weeks.
      • Cyclosporine: Serum creatinine and blood pressure every 2–4 weeks initially.
      • Azathioprine: CBC and LFTs every 4–6 weeks.
      • Mycophenolate: CBC monthly for the first 3 months, then every 3 months.
  • Preventive Measures:
    • Folic acid 1–5 mg daily with methotrexate.
    • Avoid alcohol (methotrexate, azathioprine).
    • Female Patients: Use reliable contraception (if applicable).
  • Tips for Safe and Effective Use
    • Signs of toxicity: Fever, sore throat, jaundice, decreased urine output
    • Maintain regular lab follow-up as directed by your dermatologist.
    • Report new or recurrent infections immediately.
    • Coordinate care if you require vaccinations. Live vaccines are contraindicated while immunosuppressed.
    • Discuss travel plans or upcoming surgeries with your provider to adjust dosing if needed.
  • Today, these medications are rarely used as monotherapy given the safety and efficacy profile of Biologic Medications.  However, they can be useful add-on therapies in the right situation.
  1. Oral Retinoids
  • How Oral Retinoids Work:
    • Retinoid Receptor Activation: Retinoids binds to retinoic acid receptors (RARs) in skin cells, modulating gene expression to normalize keratinocyte maturation and reduce hyperproliferation.
    • Anti-Inflammatory Effects: By influencing cytokine production (e.g., down regulating IL-6 and IL-8), retinoids calm the inflammatory response underlying psoriatic lesions.
    • Barrier Reinforcement: Improved epidermal differentiation enhances barrier function and reduces scaling and fissuring.
  • Common Oral Retinoids:
    • Acitretin (Soriatane)
      • Dosing:
        • Typical starting dose: 25 mg once daily.
  • Maintenance: 25–50 mg daily based on clinical response and tolerability.
  • Weight-Based Dosing: approximately 0.3–0.6 mg/kg/day.
  • Administration
  • Take with a fatty meal to enhance absorption.
  • Consistent timing (morning or evening) helps maintain steady blood levels
  • Particularly effective for pustular and erythrodermic psoriasis
  • Isotretinoin (Accutane, Absorica, Amnesteem, Claravis, Myorisan, Zenatane)
    • FDA approved for acne, off-label use for psoriasis
    • All patients must be enrolled in the iPledge monitoring program and obey the restrictions, so not often used for psoriasis because of administrative/monitoring burden
  • Benefits of Retinoid Therapy
    • Effective for Severe Forms of Psoriasis:
      • Demonstrated efficacy in pustular, erythrodermic, and extensive plaque psoriasis.
    • Long-Term Control:
      • Can sustain remission when used as maintenance therapy.
    • Steroid-Sparing:
      • Reduces reliance on topical corticosteroids, minimizing steroid-related side effects.
    • Complementary Therapy:
      • Often used with phototherapy (e.g., NB-UVB, PUVA) or topical agents to enhance clearance.
  • Potential Side Effects & Safety Considerations
    • Mucocutaneous Dryness:
      • Common areas of dryness include lips, skin, eyes, and nasal passages.
    • Hepatotoxicity & Lipid Changes:
      • Commonly elevates liver enzymes and triglycerides, so requires periodic laboratory monitoring.
    • Teratogenicity:
      • Absolutely contraindicated in pregnancy and those who would like to become pregnant
      • There is a teratogenic breakdown product of the medication, called etretinate, that is stored in the body’s fat and takes ~3 years to fully remove it from the fat stores after stopping the medication. 
      • Women of childbearing potential must use two forms of effective contraception during treatment and for at least 3 years after discontinuation.
      • Women cannot become pregnant while taking and for 3 years after stopping this medication.
      • Men and women cannot donate blood for 3 years after stopping this medication (in case a pregnant woman were to receive the blood).
    • Musculoskeletal Symptoms:
      • Arthralgias, myalgias, and back pain can occur.
    • Mental Health:
      • Rare reports of mood changes or depression – monitor closely if you have a history of mood disorders.
  • Tips for Safe and Effective Use
    • Laboratory Monitoring:
      • Baseline and periodic liver function tests, lipid panel, and complete blood count.
    • Moisturizing:
      • Use fragrance-free moisturizer, lip balm, and artificial tears to relieve dryness.
    • Avoid Alcohol:
      • Alcohol can increase conversion to more toxic metabolites and exacerbate liver stress.
    • Pregnancy Prevention:
      • Women with child-bearing potential must use dual contraception methods during treatment and for 3 years after stopping the medication due to the severe risk of birth defects.
    • Medication Timing:
      • Take with meals containing healthy fats (e.g., avocado, nuts) to boost absorption.
  1. Oral Phosphodiesterase-4 (PDE4) Inhibitor: Apremilast (Otezla)
  • How Oral PDE4 Inhibitors Work:
    • Cytokine Modulation: Selectively block the PDE4 enzyme in immune cells, preventing the breakdown of cyclic AMP (cAMP). Elevated cAMP levels down-regulate pro-inflammatory cytokines (TNF-α, IL-17, IL-23) and up-regulate anti-inflammatory mediators (IL-10).
    • Immune Balance: This shift in cytokine milieu reduces both skin and joint inflammation characteristic of psoriasis and psoriatic arthritis.
  • Common Oral PDE4 Inhibitors:
    • Apremilast (Otezla)
      • Dosing Regimen
        • Titration over the first 5-10 days to minimize gastrointestinal side effects.
        • Maintenance Dosing: 30 mg twice daily
      • Administration
        • Swallow tablets whole; do not crush or chew.
        • Take at the same times each day to maintain steady drug levels.
        • No injections or needles.
    • Roflumilast (Daliresp)
      • FDA approved for severe COPD, use in psoriasis is off-label
      • Rarely used in psoriasis because of the expense and so many other options available
  • Benefits of PDE4 Inhibitor Treatment
    • Convenience:
      • No injections or infusions required. Ideal for patients preferring pills.
    • Dual-Indication:
      • FDA-approved for both plaque psoriasis and psoriatic arthritis.
    • Non-Immunosuppressive Profile:
      • Does not broadly suppress the immune system like traditional immunosuppressants, reducing infection risk.
    • Long-Term Control:
      • Effective for maintenance therapy, with sustained improvement in skin clearance and joint symptoms.
  • Potential Side Effects & Safety Considerations
    • Gastrointestinal:
      • Diarrhea and nausea are most common, especially during the titration period; usually short-term and goes away.
    • Weight Loss:
      • Monitor body weight periodically; unintended weight loss can occur.
    • Headache:
      • Often mild-to-moderate.
    • Depression:
      • Rare mood changes or depression; patients with a history of depression should be monitored closely.
  • Tips for Safe and Effective Use
    • Follow the Titration Schedule:
      • Adhere closely to the dose escalation to improve gastrointestinal tolerability.
    • Stay Hydrated:
      • Adequate fluid intake can help mitigate diarrhea.
    • Consistent Dosing:
      • Take doses at the same times each day, even on weekends, to maintain even systemic drug levels.
    • Monitor Weight:
      • Keep track of any unintentional changes and report significant weight loss.
  1. Tyrosine Kinase 2 (TYK2) Inhibitors
  • How TYK2 Inhibitors Work:
    • Selective Kinase Blockade: Bind to the pseudokinase domain of the TYK2 enzyme, preventing its activation without affecting related JAK1, JAK2, or JAK3 pathways.
    • Cytokine Modulation: Inhibition of TYK2 signaling downregulates IL-23 and type I interferon pathways, both central to psoriasis pathogenesis, reducing keratinocyte proliferation and inflammation.
    • Immune Balance: By targeting a narrow subset of cytokine signals, TYK2 inhibitors offer effective immune control with a lower risk of broad immunosuppression.
  • Common TYK2 Inhibitors:
    • Deucravacitinib (Sotyktu)
      • Formulation & Dosing
        • 6 mg oral tablet once daily.
      • Indication
        • FDA-approved for adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy.
  • Benefits of TYK2 Inhibitors
    • High Efficacy:
      • Clinical trials demonstrate significant responses in psoriasis patients taking the medication by Week 16, with improvements maintained long-term.
    • Convenience:
      • Oral, once-daily dosing without injections or infusions.
    • Selective Immune Targeting:
      • Lower risk of anemia, neutropenia, and lipid elevations compared to broader JAK inhibitors.
    • Dual Indication:
      • Controls both skin and joint symptoms, making it a versatile option for patients with psoriasis and psoriatic arthritis.
    • NO black box warning (unlike other kinase inhibitor medications) for increased risk of serious infections, malignancies, clots, or death.
  • Potential Side Effects & Safety Considerations
    • Infections:
      • Upper respiratory tract infections (nasopharyngitis) are most common; monitor for fever or cough; oral herpes reactivation.
    • Gastrointestinal:
      • Diarrhea and nausea can occur, typically mild and transient.
    • Headache:
      • Report any persistent or severe headache.
    • Dermatologic:
      • Acne breakouts
    • Laboratory Changes:
      • Lipase elevations and transient changes in platelet counts; baseline and periodic monitoring recommended.
  • Tips for Safe and Effective Use
    • Adhere to Daily Dosing:
      • Take at the same time each day, with or without food.
    • Baseline Evaluation:
      • Obtain CBC, liver enzymes, lipase, and lipid panel before starting therapy.
    • Regular Monitoring:
      • Repeat labs at 4–8 weeks, then every 3 months or as advised by your provider.
    • Report Infections Promptly:
      • Any signs of infection (fever, sore throat, cough) should be evaluated.
    • Coordinate Care:
      • Inform all your healthcare providers about TYK2 therapy, especially when planning vaccinations or surgeries.

Biologic Treatment Options

Biologic therapies are targeted, systemic treatments designed to interrupt specific immune pathways that drive plaque psoriasis and psoriatic arthritis. Usually prescribed for moderate-to-severe disease or when other therapies have been insufficient, biologics offer high rates of skin clearance with favorable safety profiles.

Biologic agents have revolutionized psoriasis management by targeting precise immune pathways. Selecting the right class and agent depends on disease severity, comorbidities, patient preference, and safety considerations. 

  1. TNF-α Inhibitors
  • How They Work:
    • TNF-α inhibitors neutralize tumor necrosis factor-alpha, a cytokine central to psoriatic inflammation and keratinocyte proliferation.
  • Common TNF-α Inhibitor Medications
    • Etanercept (Enbrel)
      • 50 mg subcutaneously (SC) once weekly (or 50 mg twice weekly for initial 12 weeks)
    • Adalimumab (Humira)
      • 80 mg subcutaneously (SC) at week 0, 40 mg at week 1, then 40 mg every other week
    • Infliximab (Remicade)
      • 5 mg/kg IV infusion at weeks 0, 2, 6, then every 8 weeks
    • Certolizumab pegol (Cimzia)
      • 400 mg subcutaneously (SC) at weeks 0, 2, 4, then 200 mg every other week
  • Benefits
    • Rapid improvements in plaque thickness and itch
    • Extensive safety data spanning dermatology and rheumatology
    • Effective for both skin and joint symptoms
  • Safety & Monitoring
    • Infection risk:
      • Screen and monitor for tuberculosis and hepatitis B before starting
    • Injection-site reactions:
      • Common but usually mild
    • Rare concerns:
      • Demyelinating disease, new-onset or worsening heart failure
      • Possible increased lymphoma and skin cancer risk, although data is mixed
  • Tips for Use
    • Complete TB (Quantiferon or PPD) and hepatitis  screening prior to initiation
    • Maintain consistent dosing intervals; set calendar reminders
    • Regularly assess for signs of infection or neurological changes
  1. IL-12/23 Inhibitors
  • How They Work:
    • Target the shared p40 subunit of IL-12 and IL-23, reducing both Th1 and Th17-driven inflammation.
  • Common IL-12/23 Inhibitor Medications
    • Ustekinumab (Stelara)
      • 45 mg subcutaneously (SC) (or 90 mg if >100 kg) at weeks 0 and 4, then every 12 weeks
  • Benefits
    • Convenient dosing interval (quarterly maintenance)
    • High rates of sustained skin clearance
  • Safety & Monitoring
    • Infections:
      • Screen for TB and monitor for upper respiratory symptoms
      • Increased risk for upper respiratory infections
    • Injection-Site reactions:
      • Mild redness or itching
  • Tips for Use
    • Baseline TB screening
    • Keep a dosing calendar so that quarterly injections do not slip your mind.
    • Monitor for persistent infections.
  1. IL-17 Inhibitors
  • How They Work:
    • Block IL-17A (or its receptor) to prevent neutrophil recruitment and downstream inflammatory cascades.
  • Common IL-17 Inhibitor Medications
    • Secukinumab (Cosentyx)
      • 300 mg subcutaneously (SC) at weeks 0, 1, 2, 3, 4, then every 4 weeks
    • Ixekizumab (Taltz)
      • 160 mg subcutaneously (SC) at week 0, then 80 mg every 2 weeks through week 12, then every 4 weeks
    • Brodalumab (Siliq)
      • 210 mg subcutaneously (SC) at weeks 0, 1, 2, then every 2 weeks
  • Benefits
    • Very high psoriasis clearance rates by weeks 12–16
    • Effective for both skin and joint disease
  • Safety & Monitoring
    • Infections:
      • Increased risk of candidiasis; ask about thrush or genital yeast infections
    • Brodalumab-specific:
      • Monitor for mood changes and suicidal ideation (boxed warning)
    • IBD flares:
      • Use caution if you have inflammatory bowel disease as this class of biologic may cause a flare
  • Tips for Use
    • Inspect skin and mucosa for fungal infections regularly
    • Screen for personal or family history of depression and IBD before starting  Brodalumab
    • Keep emergency contact info accessible in case of mood-related side effects
  1. IL-23 Inhibitors
  • How They Work:
    • Selectively inhibit the p19 subunit of IL-23, disrupting Th17 cell differentiation and cytokine release.
  • Common Agents
    • Guselkumab (Tremfya)
      • 100 mg subcutaneously (SC) at weeks 0 and 4, then every 8 weeks
    • Tildrakizumab (Ilumya)
      • 100 mg subcutaneously (SC) at weeks 0 and 4, then every 12 weeks
    • Risankizumab (Skyrizi)
      • 150 mg subcutaneously (SC) at weeks 0 and 4, then every 12 weeks
  • Benefits
    • Sustained clearance with fewer injections than other biologics
    • Excellent long-term safety profile
  • Safety & Monitoring
    • Infections:
      • Mild upper respiratory infections; monitor for fever or cough
      • Lower infection rates compared with TNF-α inhibitors
    • Injection-site reactions:
      • Generally mild
    • Rare candida infections
  • Tips for Use
    • Use a smartphone reminder for every-2- or every-3-month injections
    • Continue routine age-based health screenings (e.g., mammograms, colonoscopies)

Lifestyle Tips for Managing Psoriasis

In addition to medical treatments, these everyday habits can help reduce flare-ups:

  • Moisturize daily to prevent skin dryness and irritation.
  • Use fragrance-free skin care products to reduce dermal sensitivity.
  • As much as possible, avoid and minimize known triggers like stress, illness, or injury to the skin.
  • Eat a balanced, anti-inflammatory diet rich in fruits, vegetables, lean proteins, and healthy fats.
  • Exercise regularly to support overall health and reduce inflammation.
  • Limit alcohol and avoid smoking, which can worsen symptoms.

When to See a Dermatologist

If you suspect you have psoriasis or your current psoriasis treatments aren’t working, it’s time to see one of our board-certified dermatologists. Early intervention can help manage flares, prevent complications like joint damage, and improve your long-term health outlook.

Don’t let psoriasis control your life. Whether you’re newly diagnosed or struggling with stubborn plaques, our experienced team can develop a customized plan to help you get relief. Our expert dermatology team in Denver/Lakewood specializes in the diagnosis and management of autoimmune skin conditions like psoriasis. We’ll work with you to find a personalized treatment plan that restores comfort, confidence, and skin health.mended to keep a healthy lifestyle with a good diet, exercise, and minimizing stress as much as possible.

Schedule a Consultation Today!