Psoriasis - Treating psoriasis

Treatment overview

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 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
• 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.

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

Topical treatments are usually the first treatments used for mild to moderate psoriasis. These are creams and ointments you apply to affected areas. 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 most areas of the body. 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 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, topical corticosteroids 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.

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.

Calineurin inhibitors

Calcineurin inhibitors, such as tacrolimus and pimecrolimus, are medicines that reduce the activity of the immune system and help to reduce inflammation. They are sometimes used to treat psoriasis affecting sensitive areas (such as the scalp, the genitals and folds in the skin) if topical corticosteroids are ineffective.

These medications can cause skin irritation or a burning and itching sensation when they are started, but this will usually improve within a week.

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. It may be used to treat psoriasis affecting the limbs, trunk or scalp if other topical treatments are ineffective. 

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 production of skin cells and has few side effects. However, it can burn if too concentrated.

It is 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 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).

Want to know more?

• The Psoriasis Association: first-line treatments for psoriasis
• PAPAA: emollients and psoriasis

Phototherapy

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 are not the same as using a sunbed.

UVB phototherapy

Ultraviolet B (UVB) phototherapy uses a wavelength of light invisible to human eyes. The light slows down the production of skin cells and is an effective treatment for some types of psoriasis that have not responded to topical treatment. 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 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. 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 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
• PAPAA: psoriasis and phototherapy

Systemic treatments

If your psoriasis is severe or other treatments have not 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 control psoriasis by slowing down the production of skin cells and suppressing inflammation. It is usually taken once a week.

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

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 also affect the development of sperm cells, so men should not 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 is 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 production of skin cells. It is used to treat severe psoriasis that has not responded to other non-biological systemic treatments. It is 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 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. However, it is 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 has not responded to other treatments, or if you cannot use other treatments.

Etanercept

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 it may return. You will be monitored for side effects during your treatment.

Adalimumab

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 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 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
• 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