Luckily, if topical therapies don’t bring relief, you have more options.
“The treatment of psoriasis depends on multiple things,” says Michelle Henry, MD, dermatologist. The two biggest factors are the severity and location of your psoriasis symptoms.
Treatments for psoriasis range from lifestyle changes for psoriasis (including a good skincare routine) to biologics, a medication that inhibits the immune response that causes psoriasis inflammation.
Generally speaking, the more aggressive a treatment option, the greater the side effect profile. “We always try to do the least aggressive treatments if we can, so the topical treatments are really common with psoriasis,” says Dr. Henry.
Topical therapies for psoriasis are one step more aggressive than just following a good skincare routine. They include corticosteroids, vitamin D analogs, and retinoids. For example, corticosteroids work by reducing inflammation and regulating the excess skin cell turnover that causes psoriasis plaques, according to Dr. Henry.
Many people with psoriasis are able to find relief from symptoms with topical therapies, especially when combined with lifestyle changes. However, when topical therapies don’t work, your dermatologist may recommend “walking up the ladder” to more aggressive treatment options, says Dr. Henry. (For example, learn more about the ideal candidate for biologics for psoriasis.)
So, How Do You Know If Topical Therapies Are Working?
There are a few ways doctors might gauge the success of a topical treatment for psoriasis:
Presence of plaques: Most obviously, the topical therapy is deemed unsuccessful if the psoriasis plaques don’t go away. It may take about two to four weeks for a topical therapy for psoriasis to show improvements.
Plaque surface area: Topical therapies work best when plaques are small or localized to a smaller surface area of the body. When you have numerous large plaques throughout the body, the psoriasis is “too large to be maintained with just a topical medication,” says Dr. Henry. Oral medications for psoriasis are usually more appropriate in these situations.
Chronic reliance: “We really don’t want you using topical steroids chronically for life,” says Dr. Henry. Long-term reliance on topical steroids have some side effects, such as skin thinning and stretch marks.
Adherence: Some patients have a hard time sticking to the routine of applying topical therapies. This might be reason to switch to an alternative treatment option.
“If we’re seeing any of these things, [or] we’re seeing any side effects of the medication, that might be a reason to transition to using an oral medication,” says Dr. Henry.
Worried that your topical treatment for psoriasis might not be bringing you the results you were hoping? There’s reason to stay optimistic: “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.
00:00:00.700 --> 00:00:02.666
00:00:02.667 --> 00:00:05.266
So we always try to do the least aggressive treatments
00:00:05.267 --> 00:00:09.799
if we can, so topical treatments are really common.
00:00:09.800 --> 00:00:15.666
00:00:15.667 --> 00:00:19.766
Psoriasis is a chronic, autoimmune, inflammatory condition
00:00:19.767 --> 00:00:23.766
that manifests with thick, scaly plaques, often at the elbows,
00:00:23.767 --> 00:00:26.632
the scalp, really you can have it anywhere on the body.
00:00:26.633 --> 00:00:29.866
One of the most used and mainstay treatments
00:00:29.867 --> 00:00:32.599
for psoriasis are the corticosteroids.
00:00:32.600 --> 00:00:34.599
So the topical steroids, they help to reduce
00:00:34.600 --> 00:00:37.666
that inflammation, to regulate the excess skin turnover
00:00:37.667 --> 00:00:40.332
that's causing those big, thick plaques.
00:00:40.333 --> 00:00:43.366
Coal tar has been used for centuries, really,
00:00:43.367 --> 00:00:46.166
and it's also anti-inflammatory.
00:00:46.167 --> 00:00:49.299
There are some vitamin D analogs, and then sometimes
00:00:49.300 --> 00:00:52.299
we even use topical retinoids, which are vitamin A derivatives,
00:00:52.300 --> 00:00:54.366
that help to regulate the way skin turns over.
00:00:54.367 --> 00:00:57.132
Those are also common medications.
00:00:57.133 --> 00:00:58.899
If we see that maybe we're giving you a cream
00:00:58.900 --> 00:01:00.632
and the plaque in your arm goes away
00:01:00.633 --> 00:01:02.566
but you're getting another plaque on the other arm,
00:01:02.567 --> 00:01:04.166
or you're getting more plaques on the legs,
00:01:04.167 --> 00:01:06.799
then it might mean that your overall area
00:01:06.800 --> 00:01:10.099
that has psoriasis involvement is too large
00:01:10.100 --> 00:01:12.532
to be maintained with just a topical medication.
00:01:12.533 --> 00:01:14.266
So one of the main reasons that I graduate
00:01:14.267 --> 00:01:17.232
from a topical medication to an oral medication
00:01:17.233 --> 00:01:19.466
is because of patient's body surface area
00:01:19.467 --> 00:01:21.132
of psoriasis is just far too high.
00:01:21.133 --> 00:01:23.566
The oral medications often do come
00:01:23.567 --> 00:01:27.099
with some side effects because they're not as selective
00:01:27.100 --> 00:01:29.532
in how they control the immune system
00:01:29.533 --> 00:01:33.099
as the biologic medications, so the biologic medications
00:01:33.100 --> 00:01:35.666
are actually injectable medications that work
00:01:35.667 --> 00:01:38.599
on very specific arms of the immune system
00:01:38.600 --> 00:01:41.799
to quiet them and reduce that excess scale
00:01:41.800 --> 00:01:45.132
and those plaques and that discomfort that our patients have.
00:01:45.133 --> 00:01:47.899
We really don't want you using topical steroids
00:01:47.900 --> 00:01:49.032
chronically for life.
00:01:49.033 --> 00:01:50.899
The topical steroids are safe medications,
00:01:50.900 --> 00:01:53.299
but they also have side effects: they can cause
00:01:53.300 --> 00:01:56.432
skin thinning, they can cause stretch marks of the skin,
00:01:56.433 --> 00:01:58.632
which all can be quite disturbing to a patient.
00:01:58.633 --> 00:02:01.166
If we're seeing any of those things, if we're seeing any
00:02:01.167 --> 00:02:03.699
side effects of the medication, that might be a reason
00:02:03.700 --> 00:02:06.966
to transition to using an oral medication.
00:02:06.967 --> 00:02:11.933
Over-the-counter (OTC) topicals. Portland, OR: National Psoriasis Foundation. (Accessed on February 14, 2020 at https://www.psoriasis.org/about-psoriasis/treatments/topicals/over-the-counter.)
Topical treatments. Portland, OR: National Psoriasis Foundation. (Accessed on February 14, 2020 at https://www.psoriasis.org/about-psoriasis/treatments/topicals.)
Treatment of psoriasis in adults. Waltham, MA: UpToDate, 2020. (Accessed on February 14, 2020 at https://www.uptodate.com/contents/treatment-of-psoriasis-in-adults.)