Which Psoriasis Treatment is Right for You?
You’ve likely heard of the dermatologic disease psoriasis, which affects about three percent of the population. What you might not know: Your psoriasis likely doesn’t look or feel like your coworker’s psoriasis or like the case you read about in the pamphlet at the doctor’s office.
“Psoriasis is just a word,” says Adnan Nasir, M.D., Men’s Health advisor and a dermatologist in Raleigh, NC. “It comes from the Greek word psōra, which means ‘itch’ — but not all psoriasis itches.”
There are all different kinds of psoriasis.
There’s plaque psoriasis, the most common type, which causes dry, itchy, scaly patches of skin. There’s guttate psoriasis, which might pop up after strep throat, and the list goes on.
And because psoriasis looks so different, it also has many different forms of treatment: topical creams, phototherapy (light therapy), traditional meds including steroids, and newer at-home injectables called biologics. Biologics target specific parts of the immune system directly impacted by psoriasis, and they’re a big deal in both the medical community and to many with psoriasis.
“Biologics are probably the most important advancement in the field of dermatology over the last 30 years,” says Evan A. Rieder, M.D., a dermatologist at NYU Langone. “They've revolutionized the way that we treat psoriasis and some other conditions of the skin such as eczema.”
But are they for you? Here’s what you need to know about choosing a treatment path for your psoriasis.
Treatment Options for Psoriasis
Medical treatment options for psoriasis generally fall into a few different categories.
Topical therapies
These are your creams or lotions (corticosteroids, synthetic forms of vitamin D, retinoids, and more) which are applied a few times a day and are best reserved for localized psoriasis — psoriasis that’s, say, only on your elbows or knees. “Generally, the rule of thumb is that if less than 10 percent of body surface area is affected by psoriasis, topical therapy is first-line treatment,” says Dr. Nasir.
Phototherapy
This form of light therapy uses particular wavelengths of ultraviolet light to treat psoriasis. Phototherapy works for small areas (your hands) and big ones (your trunk, legs, or arms). It’s especially effective if you notice that your psoriasis improves in sunlight or in the summer months and worsens in the winter. Phototherapy quells the overactive immune system that contributes to psoriasis. “The largest immune system in the body is the skin immune system,” explains Dr. Nasir. “Ultraviolet light causes a temporary, localized suppression of the immune system just on the patch that the light was shining on.”
You don’t need a prescription for phototherapy and you can buy the units online (companies such as Davlin, BioTech UV, or National Biological Corporation sell them for a couple hundred bucks). “The units that are ideal for psoriasis are tagged with the label ‘narrowband UVB unit,” says Dr. Nasir. Sometimes it's abbreviated ‘nb UVB.’ For the right candidates, standing in front of the lights for 30 or 40 seconds a few times a week is usually enough to “take care of quite severe, quite widespread psoriasis,” Dr. Nasir says.
Oral or injected medications
Medications you take by mouth or injection are known as “systemic” treatments. One of these systemic treatments is biologics. “Biologics suppress the cytokines, or messenger molecules, that are typically elevated in psoriasis,” says Dr. Nasir. They’re different from more traditional systemic drugs (which impact your whole immune system) because they target only the specific parts of the immune system that are impacted by psoriasis.
Are Biologics Right for Me?
It really depends. When it comes to treating psoriasis, it’s important to have a conversation with your doctor about your specific condition. That said, biologics are often a solid option for many people.
“I think biologics should be considered for any patient that has disease that is not localized,” says Corey L. Hartman, M.D., Men’s Health advisor and founder of Skin Wellness Dermatology in Birmingham, AL.
If your psoriasis impacts areas that are harder to reach with topicals (your nails or scalp), docs often consider biologics.
Some biologics can also slow or stop the process of joint damage, making them a good pick for those with joint pain or psoriatic arthritis, a form of arthritis that can impact those with psoriasis.
“Most of the biologics were actually approved for psoriatic arthritis first. If you're treating for psoriasis, you're treating for potential arthritis, too,” says Dr. Hartman. After all, sometimes, joint changes can be irreversible, he says, so prevention is key.
Biologics are also convenient. When they first came out, the injectables were administered in-office, but now they are available for home use and one injection can sometimes last months. “Insurance coverage has also changed a lot over the years,” adds Dr. Hartman, “opening the treatment up many more people.”
That said, they’re not for everyone. “We don't want to give someone systemic therapy unless they're a candidate for systemic therapy,” explains Dr. Nasir. “If somebody has psoriasis that affects two or three percent of their body surface area, even if they're put on the strongest biologic, they might only get that down to one and a half to two percent of their body surface. If somebody has psoriasis that impacts 80 percent of their body surface area, a biologic may take that down to two or three percent.”
Are There Downsides to Biologics?
As with any drug, there are some downsides to biologics. Typically, the downsides are related to the immune system’s surveillance function. “Biologics try to suppress the messengers that are typically associated with psoriasis — and for the most part, these messengers are associated with psoriasis and nothing else,” says Dr. Nasir. “But in a small number of cases, there is some spillover.” That means you may see immune system suppression in areas that don’t have to do with psoriasis. “This can lead to an increased risk of infection, autoimmune disease, or malignancy,” Dr. Nasir says.
Some early studies suggested that biologic use suppressed the immune system’s ability to spot and destroy damaging cells, increasing the risk of cancer three-fold. Other more recent research suggests no link between biologic use and cancer risk.
Dr. Rieder calls the newer generation of biologics “exceedingly safe.” He adds that side effects related to immune system suppression are rare. “These are not thought to be medications that suppress the immune system in a meaningful way to increase the risk of having infections.”
Experts like Dr. Hartman note that one day, there will be genetic testing that allows physicians to map specific disease and pair it with hyper-targeted medications, lowering any existing risks even more.
If you have certain types of heart disease, like congestive heart failure, there are some biologics you’d need to avoid, too, as some can increase heart muscle contractility and efficiency, says Dr. Nasir.
Biologics also, by their nature, require an injection (often a small auto-injector), which can be a turnoff if you don’t like needles. But dermatologists who prescribe biologics are, as Dr. Rieder notes, well-versed in “teaching people how to use them in a way that relieves their anxiety.”
If You Take Biologics, Would You Need to Take Them Forever?
It’s hard to say. On one hand, there is no cure for psoriasis, so if you opt for biologics, it’s likely something that you would continue as long as you want to control the disease, says Dr. Hartman. On the other hand, Dr. Hartman says that he has had patients with well-controlled psoriasis who “take breaks” from biologics or reduce the frequency of their injections with some success.
As you get older, psoriasis also tends to get better because your immune system weakens, says Dr. Nasir. “It's not just able to mount as robust of an autoimmune response. I always tell people, ‘you're likely to outgrow this.’”
The Bottom Line
The truth of the matter is that psoriasis affects everyone differently — and it’s best to discuss treatment strategies and timelines with your individual provider, checking in on what’s working and what’s not as the years go on.
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