As psoriasis progresses or becomes more severe, though, topical treatments may not be enough to ease your symptoms. If that’s the case, your doctor may prescribe systemic treatments to calm the source of the inflammation that causes psoriasis. The good news: There are plenty of options available, says Mark Lebwohl, MD, chairman of the dermatology department at the Icahn School of Medicine at Mount Sinai in New York and past chairman of the Psoriasis Task Force of the American Academy of Dermatology.
Signs Your Topical Treatment Isn’t Working
Topical psoriasis treatments are applied directly to your skin to reduce inflammation and tamp down overactive skin cell production, according to the National Psoriasis Foundation (NPF). They include ointments, creams, lotions, gels, and sprays. Examples of topical drugs used to treat psoriasis include:
AnthralinCoal tarCorticosteroidsRetinoidsSalicylic acid
Some people also find relief from psoriasis itch and dryness with over-the-counter skin-care products containing zinc, aloe, or capsaicin. Although many of these options work well initially, over time your psoriasis may progress to the point where they’re no longer as effective. One sign topical treatments may not be enough to manage your symptoms is if you’re seeing plaques on more areas of your body. They usually appear on your elbows, knees, lower back, and scalp. If you notice them in new areas, such as your hands or feet, or if you’re seeing more of them, even when using a topical regularly, it may be time for a systemic treatment, according to Dr. Lebwohl. He generally recommends systemic treatments for people who have psoriasis on more than 5 to 10 percent of their body. At that point, “It starts to become very impractical to use a topical,” he says. The other reason Lebwohl recommends systemic treatments is if topicals just aren’t managing your psoriasis symptoms. He says it’s important to give your treatments time to work, but topicals should have a gradual effect about a month after you start taking them. If you don’t notice a significant difference in your symptoms within three months, the treatment may not work for you.
Why Topicals May No Longer Be Enough
You may also notice that a topical treatment simply doesn’t control your symptoms like it once did. That may be because your psoriasis has become more severe or you’ve developed a tolerance to topical therapies, including steroids, which lessens their effectiveness. While there are many theories about why that happens, “I do think it’s a real phenomenon,” Lebwohl says. “They just stop working.” It’s also possible that if you stop using a topical treatment as often as your doctor prescribed, it could lose its effectiveness, according to a review published in July 2015 in the journal Psoriasis: Targets and Therapy. Although older topicals tended to be greasy ointments that were often less effective, newer topicals come in easier-to-use foams and lotions that work well for many people without the mess. These products should make it easier to stick to your treatment plan, Lebwohl notes.
Topical Versus Systemic Treatments
If your doctor determines that topicals aren’t sufficient to manage your psoriasis, they may move you to a systemic therapy, says Lebwohl. Unlike topical medications, which are applied directly to the affected area of skin, systemic psoriasis treatments are taken orally or injected and work throughout the body to help control the inflammation that causes psoriasis. They’re typically prescribed if you have moderate to severe psoriasis or your symptoms no longer respond to topical treatments. Examples of systemic treatments for psoriasis include: Conventional disease-modifying antirheumatic drugs (DMARDs): This class of drugs controls psoriasis by suppressing inflammation, according to the NPF. Conventional DMARDs, such as methotrexate and cyclosporine, reduce inflammation by suppressing the immune system on a broad level. That’s why they tend to cause more side effects than newer drugs and carry warnings about increased risk of infection, Lebwohl says. Biologics: Biologics are a type of DMARD made from living cells, according to the NPF. Unlike conventional DMARDs, which affect the immune system broadly, biologics target and block a single molecule in the immune system that’s responsible for psoriasis symptoms, explains Lebwohl. That often means fewer side effects. Taking biologics may involve going to your doctor for regular injections or infusions, or you may be able to self-inject at home. “People are often afraid of injectables, but once they use them, they realize that they can target a small part of the immune system with few side effects and have a massive effect on psoriasis,” says Lebwohl. Newer biologic drugs are particularly effective and safe, he notes. But keep in mind that some biologics may take a few months to work. “These drugs represent major breakthroughs in psoriasis,” says Lebwohl. “Almost all patients with psoriasis can be cleared today with treatments that are safe.”
Other Treatment Options
There are two additional possibilities your doctor may consider, according to Lebwohl, if topicals are no longer working for you. Steroids: Injecting steroids into individual lesions can reduce inflammation and resolve symptoms quickly, Lebwohl says, although the drugs do have some side effects. Ultraviolet (UV) therapy (phototherapy): During UV therapy, affected areas of the skin are treated with an excimer laser or other source of UVB light. “UV treatments work, and they’re safe, and many patients want them for that reason,” says Lebwohl. New UV treatment options use a very specific wavelength that treats psoriasis without increasing cancer risk, he adds. But UV therapy isn’t right for everyone, as it may require repeated treatments to work, although your doctor can prescribe a portable UV therapy device for use at home. “It’s very impractical for many people, because you have to devote a lot of time to it,” says Lebwohl.
Talking to Your Doctor About Changing Treatments
If topical therapies alone are no longer enough to manage your psoriasis, it may be time to talk to your doctor about adjusting your treatment plan. When discussing your options, it’s important to mention any joint pain or stiffness you’re experiencing. Psoriatic arthritis affects up to one-third of psoriasis patients, and the drugs that work for psoriatic arthritis may differ from those used to treat psoriasis, according to Lebwohl. That means you may need to switch medications or add one to your regimen, he says. It’s also essential to fill out the health questionnaire provided by your doctor. These forms contain all of the essential information your doctor needs to determine the right treatment for you, and having it in writing saves valuable time during your appointment. Talk to your doctor about whether they’re open to prescribing all psoriasis drugs, including biologics, Lebwohl suggests. He notes that not all doctors consider all available psoriasis treatments — especially biologics, which are more complicated to prescribe. “But many of these drugs result in 90 percent improvement in a large majority of patients,” Lebwohl says. Your doctor will decide which treatment option is right for you by considering many factors, including your preferences, medical history, and risk of related conditions. In other words, the drug that will help you is individual to you. “Every patient and each drug has unique characteristics that determine the optimal treatment,” says Lebwohl. If you need to find a dermatologist or are looking for a second opinion about your treatment options, visit the NPF’s Patient Navigation Center.
