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.
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So we always try to do the least aggressive treatments
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if we can, so topical treatments are really common.
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Psoriasis is a chronic, autoimmune, inflammatory condition
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that manifests with thick, scaly plaques, often at the elbows,
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the scalp, really you can have it anywhere on the body.
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One of the most used and mainstay treatments
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for psoriasis are the corticosteroids.
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So the topical steroids, they help to reduce
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that inflammation, to regulate the excess skin turnover
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that's causing those big, thick plaques.
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Coal tar has been used for centuries, really,
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and it's also anti-inflammatory.
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There are some vitamin D analogs, and then sometimes
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we even use topical retinoids, which are vitamin A derivatives,
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that help to regulate the way skin turns over.
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Those are also common medications.
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If we see that maybe we're giving you a cream
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and the plaque in your arm goes away
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but you're getting another plaque on the other arm,
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or you're getting more plaques on the legs,
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then it might mean that your overall area
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that has psoriasis involvement is too large
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to be maintained with just a topical medication.
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So one of the main reasons that I graduate
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from a topical medication to an oral medication
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is because of patient's body surface area
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of psoriasis is just far too high.
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The oral medications often do come
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with some side effects because they're not as selective
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in how they control the immune system
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as the biologic medications, so the biologic medications
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are actually injectable medications that work
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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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We really don't want you using topical steroids
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chronically for life.
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The topical steroids are safe medications,
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but they also have side effects: they can cause
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skin thinning, they can cause stretch marks of the skin,
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which all can be quite disturbing to a patient.
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If we're seeing any of those things, if we're seeing any
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side effects of the medication, that might be a reason
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to transition to using an oral medication.
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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.)