Here’s how derms walk up the “therapeutic ladder” for psoriasis treatment.
The treatment of psoriasis—an autoimmune disease that creates red, scaly plaques on the skin—depends on multiple factors, but two big factors include the severity and the location of the symptoms, according to Michelle Henry, MD, dermatologist in New York City and clinical instructor at Weill Cornell Medical College.
Topical treatments are the mainstay of treatments for psoriasis. These creams and gels are applied directly to the skin, so they can help reduce the inflammation that’s causing symptoms while causing fewer systemic side effects to the rest of the body.
However, topical treatments aren’t always right, or enough, for all individuals with psoriasis. For example, topical treatments may not be a good fit for someone who has psoriasis plaques covering large portions of the body. Other patients may try topical treatments but not see an improvement in their symptoms. Here are signs your topical psoriasis treatments are working.
“We have a therapeutic ladder where we start with the mildest treatments, and we become more aggressive as the patient needs,” says Dr. Henry.
When topical treatments aren’t enough, a dermatologist may suggest UV light therapy (either instead of or in addition to topical treatments). “UV light is somewhat anti-inflammatory, and so for the right patient, UV light is a common and effective tool for psoriasis,” says Dr. Henry.
A benefit of UV light therapy, also called phototherapy, is that it can help treat psoriasis that covers large areas of the body. One downfall is that it sometimes requires multiple treatments a week, so it may not be feasible if someone has a challenging schedule to work with.
“If we’re walking up the ladder, and maybe UV light and topical treatments aren’t working, we then graduate to using maybe some of the oral medications,” says Dr. Henry.
Unlike topical therapy and light therapy, oral medications are a systemic treatment for psoriasis, meaning it targets the whole body instead of individual areas of plaques. For this reason, oral medications can be very useful for people whose psoriasis symptoms cover more than 5 percent of their body surface area.
Oral medications are classified as either immunosuppressive or immunomodulatory drugs. Essentially, they suppress or modify how the immune system works to calm the immune response that’s causing psoriasis symptoms.
There are many oral medications for psoriasis to choose from, so a dermatologist can really cater the selection to you based on what other comorbidities you have (such as psoriatic arthritis) and the side effect profile of the medication.
Biologics are the most aggressive form of treatment against psoriasis, and they’re the most effective against more severe types of psoriasis. Instead of simply suppressing the immune system, they block the action of specific cells or proteins in the immune system that cause psoriasis.
“The biologic medications are actually injectable medications that work on very specific arms of the immune system to quiet them and reduce that excess scale, and those plaques, and that discomfort that our patients have,” says Dr. Henry. Learn more about biologic therapy for psoriasis here.
However, biologic medications are typically more costly than treatments lower on the therapeutic ladder, and they tend to come with more side effects, so—as is true for all medications—the benefits have to be weighed against the risks. In this case, biologic agents are recommended and considered beneficial to people with severe symptoms and with a high risk of complications (such as joint destruction).
“We’re really in a great time that if you have psoriasis, there is hopefully a treatment for you because we have a wide range of treatments that are quite effective,” says Dr. Henry.
Dr. Henry is a board-certified dermatologist and dermatologic surgeon in New York City, and a clinical instructor at Weill Cornell Medical College.
00:00:00.667 --> 00:00:02.432
(gentle piano music)
00:00:02.433 --> 00:00:04.966
The treatment of psoriasis depends on multiple things.
00:00:04.967 --> 00:00:07.399
One, the severity of your psoriasis,
00:00:07.400 --> 00:00:10.532
and the location of your psoriasis.
00:00:10.533 --> 00:00:15.666
(gentle piano music)
00:00:15.667 --> 00:00:17.866
Psoriasis is an autoimmune condition,
00:00:17.867 --> 00:00:19.366
and instead of attacking the bad things,
00:00:19.367 --> 00:00:20.699
it's attacking the skin.
00:00:20.700 --> 00:00:22.899
The immune system's preoccupation with the skin
00:00:22.900 --> 00:00:24.232
is what's causing that thickening
00:00:24.233 --> 00:00:27.299
and that excess turnover and creating those plaques.
00:00:27.300 --> 00:00:28.566
We have a therapeutic ladder
00:00:28.567 --> 00:00:30.832
where we start with the mildest treatments,
00:00:30.833 --> 00:00:33.466
and we become more aggressive as the patient needs.
00:00:33.467 --> 00:00:35.599
If topical medications aren't working,
00:00:35.600 --> 00:00:38.532
sometimes we'll use them in addition to UV light.
00:00:38.533 --> 00:00:41.399
UV light is somewhat anti-inflammatory,
00:00:41.400 --> 00:00:43.266
and so for the right patient,
00:00:43.267 --> 00:00:46.832
UV light is a common and effective tool for psoriasis.
00:00:46.833 --> 00:00:48.832
UV light is great because you really can use it
00:00:48.833 --> 00:00:51.066
over a wide area on the body.
00:00:51.067 --> 00:00:53.099
It can be a little bit cumbersome because oftentimes
00:00:53.100 --> 00:00:56.799
patients need treatments multiple times a week,
00:00:56.800 --> 00:01:00.299
but it's a nice next step if the patient can,
00:01:00.300 --> 00:01:03.566
A, tolerate it, and B, their schedule allows for it.
00:01:03.567 --> 00:01:06.532
If we're walking up the ladder, and maybe UV light
00:01:06.533 --> 00:01:08.199
and topical treatments aren't working,
00:01:08.200 --> 00:01:11.232
we then graduate to using maybe some of the oral medications,
00:01:11.233 --> 00:01:14.232
so give those oral anti-inflammatory medications
00:01:14.233 --> 00:01:17.966
to slow down that process, reduce that excess skin turnover,
00:01:17.967 --> 00:01:19.566
and reduce the plaques.
00:01:19.567 --> 00:01:22.866
We have a whole range of oral medications,
00:01:22.867 --> 00:01:26.232
and I choose the oral medication based on the patient,
00:01:26.233 --> 00:01:28.899
whatever comorbidities they may have,
00:01:28.900 --> 00:01:31.499
looking at the side effect profile of the medication.
00:01:31.500 --> 00:01:33.899
I try to find the specific medication that will work best
00:01:33.900 --> 00:01:36.566
for them because they're not as selective
00:01:36.567 --> 00:01:38.566
as the next category of medications:
00:01:38.567 --> 00:01:40.566
the biologic medications.
00:01:40.567 --> 00:01:44.066
So the biologic medications are actually injectable medications
00:01:44.067 --> 00:01:47.366
that work on very specific arms of the immune system
00:01:47.367 --> 00:01:50.599
to quiet them and reduce that excess scale,
00:01:50.600 --> 00:01:54.232
and those plaques, and that discomfort that our patients have.
00:01:54.233 --> 00:01:56.999
So we're really in a great time that if you have psoriasis,
00:01:57.000 --> 00:01:59.799
there is hopefully a treatment for you
00:01:59.800 --> 00:02:01.166
because we have a wide range of treatments
00:02:01.167 --> 00:02:03.399
that are quite effective.
00:02:03.400 --> 00:02:07.800
(gentle acoustic music)
Moderate to severe psoriasis and psoriatic arthritis: biologic drugs. Portland, OR: National Psoriasis Foundation. (Accessed on March 2, 2020 at https://www.psoriasis.org/about-psoriasis/treatments/biologics.)
New oral treatments. Portland, OR: National Psoriasis Foundation. (Accessed on March 2, 2020 at https://www.psoriasis.org/about-psoriasis/treatments/oral-treatments.)
Phototherapy. Portland, OR: National Psoriasis Foundation. (Accessed on March 2, 2020 at https://www.psoriasis.org/about-psoriasis/treatments/phototherapy.)
Treatment of psoriasis in adults. Waltham, MA: UpToDate, 2020. (Accessed on March 2, 2020 at https://www.uptodate.com/contents/treatment-of-psoriasis-in-adults.)