Treating psoriasis

Treatment overview

Treatments are determined by the type and severity of your psoriasis and the area of skin affected. Yourdoctor 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.

Awide range of treatmentsare availablefor psoriasis, but identifying which treatment is most effective can be difficult. Talk to yourdoctor if you feel a treatment isn't working or you have uncomfortable side effects.

Treatments fall into three categories:

• topical creams and ointments thatare applied to your skin
• phototherapy your skin is exposed to certain types of ultravioletlight
• 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.

The various treatments forpsoriasis are outlined below. You can also read a summary of the pros and cons of the treatments for psoriasis , allowing you to compare your treatment options.

Want to know more?

• National Institute for Health and Care Excellence (NICE):The assessment and management of psoriasis
• PAPAA: psoriasis treatments

• Topical treatments

  Topical treatments are usually the first treatments used for mild to moderatepsoriasis. These are creams and ointments you apply to affected areas.

  Some people find that topical treatmentsare alltheyneed to control their condition, althoughit may take up to six weeks beforethere's a noticeable effect.

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

  Emollients

  Emollients are moisturising treatments applied directly to the skin to reduce water loss and cover it with a protective film. If you have mild psoriasis, an emollient is probably the first treatment your GP will suggest.

  The main benefit of emollients is to reduce itching and scaling. Some topical treatments are thought to work better on moisturised skin. It's important to wait at least half an hour before applying a topical treatment after an emollient.

  Emollients are availableas a widevariety of products and can be bought over the counter from a pharmacyor prescribed by your GP, nurse or health visitor.

  The treatment works by reducing inflammation. This slows the production of skin cells and reduces 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 ofskin 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 ofsteroid creamsfor 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.

  Examples of vitamin D analogues are calcipotriol, calcitriol and tacalcitol. There are very few side effects, as long as you don'tuse more than the recommended amount.

  Calcineurin inhibitors

  Calcineurin inhibitors,such astacrolimus and pimecrolimus,are ointments or creams that reduce the activity of the immune system and help to reduce inflammation. They're sometimes used to treat psoriasis affecting sensitive areas (such as the scalp, the genitals and folds in the skin) ifsteroid creamsaren't effective.

  These medications can cause skin irritation or a burning and itching sensation when they're started, but this usually improves within a week.

  Coal tar

  Coal tar is a thick, heavy oil and is probably the oldest treatment for psoriasis. How it works isn't exactly known, but it can reduce scales, inflammation and itchiness. It may be used to treat psoriasisaffecting the limbs, trunk or scalp if other topical treatments aren't effective.

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

  It's 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's applied to your skin (while wearing gloves) and left for 10to 60 minutes before being washed off.

  Dithranol can be used in combination with phototherapy (see below).

  Want to know more?

  • The Psoriasis Association:treatments from a GP
  • PAPAA: emollients and psoriasis

• The Psoriasis Association: treatments for a dermatologist

• Systemic treatments

  If your psoriasis is severeor other treatments haven't worked, you may be prescribed systemic treatments by a specialist. Systemic treatments aretreatments 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

  Methotrexatecan help to control psoriasis by slowing downthe production of skin cells and suppressing inflammation. It's usually taken once a week.

  Methotrexate can cause nausea andmay affect the production of blood cells. Long-term use can cause liver damage. People who have liver disease shouldn't take methotrexate, and you shouldn't drink alcohol when taking it.

  Methotrexate can be very harmful to a developing baby, so it'simportant that women use contraception and don't 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 shouldn't 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's 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 the production of skin cells. It's used to treat severe psoriasis that hasn't responded to other non-biological systemic treatments. It's usually taken daily.

  Acitretinhas a wide range of side effects, including dryness and cracking of the lips, dryness of the nasal passagesand, in rarer cases, hepatitis .

  Acitretin can be very harmful to a developing baby, so it's important that women use contraception and don't become pregnant while they take this drug, and for two years after they stop taking it. However, it's safe for a man taking acitretinto fathera baby.

  Biological treatments

  Biological treatments reduce inflammation by targeting overactive cells in the immune system.These treatments are usually used if youhave severe psoriasis that hasn't responded to other treatments, or if you can't use other treatments.

  Etanercept

  Etanercept is injected twice a week and you'll be shown how to do this. If there's 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's a risk of serious side effects, including severe infection. If you had Tuberculosis (TB) in the past, there's a riskit may return. You'll be monitored for side effects during your treatment.

  Adalimumab

  Adalimumab is injected once every two weeks and you'll be shown how to do this. If there's no improvement in your psoriasis after 16 weeks, the treatment will be stopped.

  Adalimumab can be harmful to a developing baby, so it's important that women use contraception and don't 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's a risk of serious side effects, including severe infections. You'll be monitored for side effects during your treatment.

  Infliximab

  Infliximab is given as a drip (infusion) into your vein at the hospital. You'll have three infusions in the first six weeks, then one infusion every eight weeks. If there's 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's a risk of serious side effects, including severe infections. You'll 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's 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's a risk of serious side effects, including severe infections. You'll be monitored for side effects during your treatment.

  Want to know more?

  • 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