Psoriasis might seem like a “skin problem,” but it’s actually an immune system disorder. The plaques and other psoriasis symptoms occur when the immune system’s T cells, which normally fight infection, start attacking healthy skin cells.
Newer cells are forced to the surface, creating those telltale thick, silvery plaques. Some psoriasis treatments will target those plaques to help shrink them and make them less dry and itchy; others work on the immune system itself, holding it back from attacking healthy cells to stop psoriasis symptoms in their tracks.
The kind of psoriasis treatment your dermatologist recommends will depend on how serious your psoriasis symptoms are (mild, moderate, or severe) and where they’re located.
The traditional approach is to start with the mildest treatments — topical creams and ultraviolet light therapy — and then progress to stronger ones only if necessary due to the side effects of these stronger options.
Here’s a look at the different ways psoriasis can be treated.
Psoriasis can leave the skin feeling parched, so you’ll want to get some of that moisture back in. Your best bet is to stick with a basic, ultra-hydrating emollient that will seal in the hydration, like Vaseline, Eucerin, or Aquaphor. “You don’t want to use moisturizers that are overly fragrant or have a lot of additives, because they could sting,” says Dr. Rossi.
One method called “occlusion” helps calm pain quicker than other home remedies. It involves applying moisturizer or oil to sore areas and wrapping them with plastic wrap or covering them with socks, a plastic bag, or gloves (if the soreness is in the hands or feet).
Salicylic acid, an ingredient found in certain moisturizers, encourages the skin to self-exfoliate, so it can reduce the scaliness of psoriasis by getting rid of debris and excess proteins called keratins. As a bonus, your other medications might see a boost and work more effectively as that tough layer of skin cells peels away. “If there’s a lot of scale on top, it can be hard for other medications to penetrate,” says Dr. Rossi.
Topical corticosteroid creams
Topical steroids don’t just ease the itchiness and pain of your skin plaques; they slow skin cell turnover by suppressing the immune system. Topical steroids are useful during flare-ups but if you rely on them long term, you could run the risk of thinning out your skin, says Anthony Rossi, MD, FAAD, board-certified dermatologic surgeon at Memorial Sloan Kettering Cancer Center and assistant professor of dermatology at Weill Cornell Medical College.
Vitamin D analogues
Vitamin D, the “sunshine vitamin” your body makes from being exposed to UV light, is important for keeping your skin healthy. Having low vitamin D levels won’t cause psoriasis, but people with psoriasis do tend to be deficient in vitamin D. A vitamin D cream or oral medication can slow skin cell growth and “help to rebalance or normalize the way your immune system is responding,” says Sandra Johnson, MD, FAAD, a board-certified dermatologist in Fort Smith, Arkansas. Vitamin D will also encourage healthier skin cells to grow.
Vitamin A derivatives called retinoids encourage old skin cells to make way for newer ones, which can help eliminate those psoriasis plaques. “It helps the cells to change over into mature cells, into better cells,” says Dr. Rossi.
UV light can suppress the immune system, “but we don’t recommend people go out and get a sunburn,” says Dr. Rossi. Instead, dermatologists use machines that emit UV light with shorter (and safer) wavelengths than you’d get from the sun or a tanning bed. (Never use a tanning bed to attempt to treat your psoriasis.) Most will use narrow-band UVB lights, but you might also have the option of psoralen and ultraviolet A (PUVA).
Patients with severe psoriasis or who are dealing with psoriatic arthritis might want to consider biologics such as alefacept, efalizumab, and infliximab, which get to the root of the problem — inflammation from the immune system — rather than just easing the physical symptoms of psoriasis. Delivered as an injection or through an IV, biologic medications prevent psoriasis flare-ups by targeting and tamping down the immune system cells that have been attacking your healthy cells.
The risk is that when you keep the immune system from doing what it’s not supposed to do, you also keep it from doing what it is supposed to do: fight an infection.
However, if your psoriasis is moderate to severe and has not responded to other treatments, you should be assured that biologics are safe. Your doctor would never prescribe a drug for which the potential side effects outweighed the benefits of better controlling your psoriasis. “I like using the targeted biologic medicines, especially the newer ones, that are very safe and effective to normalize the immune system,” says Dr. Johnson.
Oral disease-modifying treatments
Oral medications like methotrexate and cyclosporine work by suppressing the immune system to treat psoriasis from the inside out. They are less expensive than biologics, but they aren’t always preferred, because they’re not as targeted in how they address the immune system. This means they could have more side effects than biologics, says Dr. Johnson. Oftentimes, they’re paired with a topical medication.
This newer category of medication is considered a targeted therapy that affects a certain pathway in the immune system that causes inflammation in plaque psoriasis. PDE-4 inhibitors aren’t considered biologics, per se (and they’re taken orally) but they’re more targeted than traditional disease-modifying drugs like methotrexate or cyclosporine.