Psoriasis: How to Make Treatment Decisions

“They will need a systemic agent which is a treatment that works throughout the body,” she continues. “I also try to understand initially if they have psoriatic arthritis. If so, then a systemic or biological agent will be necessary. Sometimes patients will have psoriasis in sensitive areas like their scalp, groin, fingernails, hands and feet. It may be a limited area, but it can still have a major effect on their overall quality of life. In that case, I might prescribe a systemic agent more quickly, adds Dr. Stein Gold.

Treatment options

We have a wealth of options for psoriasis patients and we’re starting to understand the mechanism of the disease more quickly,’ says Dr. Stein Gold. Our newer agents are more focused on the pathogenesis (the origin and development) of the disease and can target the specific area that is abnormal.

Topicals

Topicals are most often recommended for newly diagnosed patients, or those with mild psoriasis. This first-line treatment is applied directly to your affected skin area with either lotion, cream, or foam. They work by reducing inflammation and slowing down, or putting the brakes on excessive immune cell production.

• Topical steroids. Corticosteroid ointments or creams are the most common treatment for psoriasis flareups and can reduce swelling, redness and itching. Steroid medications come in different strengths that range from strong to less potent. Low strength versions can be bought over-the-counter (OTC), but you’ll need a prescription for stronger steroids. Since prescription-strength steroids can have side effects such as burning or thinning of your skin, you should avoid using them on sensitive areas of your body such as your face, genitals or armpits.
• Topical non-steroids. Your doctor might suggest a non-steroidal topical treatment. These medications include synthetic vitamin D3 (Calcipotriol) and Vitamin A, calcium inhibitors, retinoids, salicylic acid (scalp and shampoo solutions), as well as coal tar and anthralin. Side effects include skin drying, rash, peeling and in some cases, a worsening of your psoriasis.

There are also a number of new topical agents including non-steroids such as Tapinarof. The drug’s data shows that patients can obtain clear skin and can go on a drug-free holiday for approximately four months, says Dr. Stein Gold. Another one is Reflumilast, specifically for skinfolds and sensitive areas. It’s quite targeted and highly effective. Both have recently received FDA approval.

Phototherapy

Phototherapy (light therapy) will not cure your condition, but it can reduce the size, itchiness and the appearance of psoriasis. Light therapy works by exposing the skin to ultraviolet light on a regular basis and slowing down the excess growth of skin cells, which reduces plague formation. Under medical supervision, you can receive light therapy at your healthcare provider’s office, a designated phototherapy unit, or at home.

Your psoriasis should improve within two to four weeks. But keep in mind that everyone’s skin reacts differently. Although the benefit of treatment varies from patient-to-patient, average remission time is three to 12 months. The possible side effects include mild sunburn, a stinging or itching sensation, an increased likelihood of cold sores (this is more likely if you’ve had them before), as well as premature aging of the skin. Your risk of getting skin cancer also increases with long-term exposure to light therapy.

Systemic treatments

Systemic treatments may be suggested by your healthcare provider if your psoriasis is more persistent and topicals or phototherapy are not helping your condition.

Systemic treatments are not just aimed at the affected skin area, but work throughout your body and are taken orally or by injection or intravenously. We find that systemic, particularly biologic agents are highly safe and effective,
says Dr. Stein Gold.

Oral /Intravenous or Injected Medications

• Methotrexate. (Taken orally by pills or liquid form, intravenously or by injection) Approved by the FDA more than four decades ago, this classic systemic treatment works as an immunosuppressant that inhibits fast dividing cells. It’s typically delivered as one dose or divided into three dosages over a 24-hour period. The most common side effects are fatigue, nausea, and headaches.
• Apremilast (Otezia). (Taken orally by pill or in liquid form) This medication treats psoriasis and psoriatic arthritis by regulating inflammation within the cell and inhibiting an enzyme known as phosphodiesterase 4 (PDE4). This is the enzyme that controls much of the inflammatory action within cells, which can affect the level of inflammation associated with psoriasis. Side effects include nausea, diarrhea, headache and upper respiratory tract
  infection.
• Cyclosporine. (Taken orally by pill or liquid form) This fast-acting medication is aimed at severe, difficult to manage and acute flares. Because of the drug’s potential for serious side effects including kidney issues and high blood pressure, it isn’t prescribed as a long-term treatment.
• Biologics. (Administered by injection or IV transfusion) Unlike other systemic medications, biologics only target specific parts of the immune system and are exclusively injected or delivered through transfusion. The biologics used to treat psoriasis work by blocking the action of a specific type of immune cell called a T-cell. Or, they block proteins in the immune system that play a big part in psoriasis. Although biologic medications are administered either intravenously or by injection, they are not a one-shot deal. Treatments often need to continue as long as the medication is working. Biologics have another downside: they can increase your risk of infection such as a fever, cough, or flu-like symptoms. If you’re taking a biologic and you are experiencing a side effect, contact your healthcare provider right away.

Making treatment decisions

You can help your doctor make more informed decisions regarding your treatment by sharing information about your condition and your medical history. For example, whether you have a history of heart disease, IBS, MS or prior cancers and if you have arthritis or a history of infections including TB or hepatitis, says Dr Stein Gold.

You should also feel comfortable asking your healthcare provider questions. By asking questions, you’ll know what to expect from your treatment and your psoriasis.

Questions to Ask Your Doctor

• Will my therapy be long-term or will there be times when I don’t need treatment?
• How much will my treatments cost and will my insurance company limit my choices of treatment?
• Are there certain medical conditions that will prevent me from getting systemic treatment?
• Will I need different medications for different parts of my body like my scalp and elbows?
• If my psoriasis isn’t really bothering me too much, do I really need treatment?

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