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.
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The treatment of psoriasis depends on multiple things.
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One, the severity of your psoriasis,
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and the location of your psoriasis.
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Psoriasis is an autoimmune condition,
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and instead of attacking the bad things,
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it's attacking the skin.
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The immune system's preoccupation with the skin
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is what's causing that thickening
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and that excess turnover and creating those plaques.
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We have a therapeutic ladder
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where we start with the mildest treatments,
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and we become more aggressive as the patient needs.
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If topical medications aren't working,
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sometimes we'll use them in addition to UV light.
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UV light is somewhat anti-inflammatory,
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and so for the right patient,
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UV light is a common and effective tool for psoriasis.
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UV light is great because you really can use it
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over a wide area on the body.
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It can be a little bit cumbersome because oftentimes
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patients need treatments multiple times a week,
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but it's a nice next step if the patient can,
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A, tolerate it, and B, their schedule allows for it.
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If we're walking up the ladder, and maybe UV light
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and topical treatments aren't working,
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we then graduate to using maybe some of the oral medications,
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so give those oral anti-inflammatory medications
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to slow down that process, reduce that excess skin turnover,
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and reduce the plaques.
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We have a whole range of oral medications,
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and I choose the oral medication based on the patient,
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whatever comorbidities they may have,
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looking at the side effect profile of the medication.
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I try to find the specific medication that will work best
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for them because they're not as selective
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as the next category of medications:
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the biologic medications.
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So the biologic medications are actually injectable medications
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that work on very specific arms of the immune system
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to quiet them and reduce that excess scale,
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and those plaques, and that discomfort that our patients have.
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So we're really in a great time that if you have psoriasis,
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there is hopefully a treatment for you
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because we have a wide range of treatments
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that are quite effective.
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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.)