If these are ineffective or your condition is more severe, a treatment called phototherapy may be used. Phototherapy involves exposing your skin to certain types of ultraviolet light. In the most severe cases where other treatments are ineffective, systemic treatments may be used. These are oral or injected medicines that work throughout the whole body.
Treatments are determined by the type and severity of your psoriasis and the area of skin affected. Your doctor will probably start with a mild treatment, such as topical creams (which are applied to the skin), and then move on to stronger treatments if necessary.
A wide range of treatments are available for psoriasis, but identifying which treatment is most effective can be difficult. Talk to your doctor if you feel a treatment is not working or you have uncomfortable side effects.
Topical treatments are usually the first treatments used for mild to moderate psoriasis. These are creams and ointments you apply to affected areas. They are all that some people need to control their condition. If you have scalp psoriasis, a combination of shampoo and ointment may be recommended.
Topical corticosteroids are commonly used to treat mild to moderate psoriasis in most areas of the body. The treatment works by reducing inflammation. This slows the production of skin cells and reduces the symptoms of itching. Topical corticosteroids range in strength from mild to very strong. Only use topical corticosteroids when recommended by your doctor. Stronger topical corticosteroids can be prescribed by your GP and should only be used on small areas of skin or on particularly thick patches. Overusing topical corticosteroids can lead to skin thinning.
Vitamin D analogues
Vitamin D analogue creams are commonly used along with, or instead of, topical corticosteroids for mild to moderate psoriasis affecting areas such as the limbs, trunk or scalp. They work by slowing the production of skin cells. They also have an anti-inflammatory effect. Types of vitamin D analogues include calcipotriol, calcitriol and tacalcitol. There are very few side effects, as long as you do not use more than the recommended amount.
Calcineurin inhibitors, such as tacrolimus and pimecrolimus, are medicines that reduce the activity of the immune system and help to reduce inflammation. They are sometimes used to treat psoriasis affecting sensitive areas (such as the scalp, the genitals and folds in the skin) if topical corticosteroids are ineffective.
These medications can cause skin irritation or a burning and itching sensation when they are started, but this will usually improve within a week.
Coal tar is a thick, heavy oil and is probably the oldest treatment for psoriasis. How it works is not exactly known, but it can reduce scales, inflammation and itchiness. It may be used to treat psoriasis affecting the limbs, trunk or scalp if other topical treatments are ineffective. Coal tar can stain clothes and bedding and has a strong smell. It can be used in combination with phototherapy (see below).
Dithranol has been used for over 50 years to treat psoriasis. It has been shown to be effective in suppressing production of skin cells and has few side effects. However, it can burn if too concentrated.
It is typically used as a short-term treatment for psoriasis affecting the limbs or trunk under hospital supervision as it stains everything it comes into contact with, including skin, clothes and bathroom fittings. It is applied to your skin (while wearing gloves) and left for 10 to 60 minutes before being washed off. Dithranol can be used in combination with phototherapy.
Phototherapy uses natural and artificial light to treat psoriasis. Artificial light therapy can be given in hospitals and some specialist centres, usually under the care of a dermatologist. These treatments are not the same as using a sunbed.
Ultraviolet B (UVB) phototherapy uses a wavelength of light invisible to human eyes. The light slows down the production of skin cells and is an effective treatment for some types of psoriasis that have not responded to topical treatment. Prior to treatment starting, you will have a short test to ascertain your skin type. Treatments are generally administered twice a week over a period of 15 weeks (maximum 30 sessions), with the dosage being gradually increased with each session. Goggles must be worn while in the UVB chamber in order to protect your eyes. The nurse in charge of your treatment will check for any moles and will apply total sunblock to them.
This treatment may be used in cases in which psoriasis has not responded to topical treatments. You may continue to use topical steroid creams throughout your treatment, but you must not apply them on your treatment days (before entering the light chamber). Possible side effects of the treatment include burning, itchy or dry skin, increased light sensitivity, cold sores and folliculitis (inflammation of hair follicles).
Psoralen plus ultraviolet A (PUVA)
For this treatment, you will first be given a tablet containing compounds called psoralens, or psoralen may be applied directly to the skin. This makes your skin more sensitive to light. Your skin is then exposed to a wavelength of light called ultraviolet A (UVA). This light penetrates your skin more deeply than ultraviolet B light.
This treatment may be used if you have severe psoriasis that has not responded to other treatment. Side effects of the treatment include nausea, headaches, burning and itchiness. You may need to wear special glasses for 24 hours after taking the tablet to prevent the development of cataracts. Long-term use of this treatment is not encouraged as it can increase your risk of developing skin cancer.
Combination light therapy
Combining phototherapy with other treatments often increases its effectiveness. Some doctors use UVB phototherapy in combination with coal tar, as the coal tar makes the skin more receptive to light. Combining UVB phototherapy with dithranol cream may also be effective (this is known as Ingram treatment).
If your psoriasis is severe or other treatments have not worked, you may be prescribed systemic treatments by a specialist. Systemic treatments are treatments that work throughout the entire body. These medications can be very effective in treating psoriasis but they all have potentially serious side effects. All the systemic treatments for psoriasis have benefits and risks. Before starting treatment, talk to your doctor about your treatment options and any risks associated with them.
There are two main types of systemic treatment, called non-biological (usually given as tablets or capsules) and biological (usually given as injections). These are described in more detail below.
Methotrexate can help control psoriasis by slowing down the production of skin cells and suppressing inflammation. It is usually taken once a week. Methotrexate can cause nausea and may affect production of blood cells. Long-term use can cause liver damage. People who have liver disease should not take methotrexate and you should not drink alcohol when taking it. Methotrexate can be very harmful to a developing baby, so it is important that women use contraception and do not become pregnant while they take this drug and for three months after they stop. Methotrexate can also affect the development of sperm cells, so men should not father a child during treatment and for three weeks afterwards.
Ciclosporin is a medicine that suppresses your immune system (immunosuppressant). It was originally used to prevent transplant rejection but has proved effective in treating all types of psoriasis. It is usually taken daily. Ciclosporin increases your chances of kidney disease and high blood pressure, which will need to be monitored.
Acitretin is an oral retinoid that reduces production of skin cells. It is used to treat severe psoriasis that has not responded to other non-biological systemic treatments. It is usually taken daily. Acitretin has a wide range of side effects, including dryness and cracking of the lips, dryness of the nasal passages and, in rarer cases, hepatitis. Acitretin can be very harmful to a developing baby, so it is important that women use contraception and do not become pregnant while they take this drug and for two years after they stop taking it. However, it is safe for a man taking acitretin to father a baby.
Biological treatments reduce inflammation by targeting overactive cells in the immune system. These treatments are usually used if you have severe psoriasis that has not responded to other treatments, or if you cannot use other treatments.
Etanercept is injected twice a week and you will be shown how to do this. If there is no improvement in your psoriasis after 12 weeks, the treatment will be stopped. The main side effect of etanercept is a rash where the injection is given. However, as etanercept affects the whole immune system, there is a risk of serious side effects including severe infection. If you had tuberculosis in the past, there is a risk it may return. You will be monitored for side effects during your treatment.
Adalimumab is injected once every two weeks and you will be shown how to do this. If there is no improvement in your psoriasis after 16 weeks, the treatment will be stopped. Adalimumab can be harmful to a developing baby, so it is important that women use contraception and do not become pregnant while they take this drug and for five months after the treatment finishes. The main side effects of adalimumab include headaches, a rash at the injection site and nausea. However, as adalimumab affects the whole immune system, there is a risk of serious side effects including severe infections. You will be monitored for side effects during your treatment.
Infliximab is given as a drip (infusion) into your vein at the hospital. You will have three infusions in the first six weeks, then one infusion every eight weeks. If there is no improvement in your psoriasis after 10 weeks, the treatment will be stopped. The main side effect of infliximab is a headache. However, as infliximab affects the whole immune system, there is a risk of serious side effects including severe infections. You will be monitored for side effects during your treatment.
Ustekinumab is injected at the beginning of treatment, then again four weeks later. After this, injections are every 12 weeks. If there is no improvement in your psoriasis after 16 weeks, the treatment will be stopped. The main side effects of ustekinumab are a throat infection and a rash at the injection site. However, as ustekinumab affects the whole immune system, there is a risk of serious side effects including severe infections. You will be monitored for side effects during your treatment.