Treatment Options for Plaque Psoriasis

1. Topical Treatments

Topical treatments are usually the first line of therapy for mild to moderate plaque psoriasis. These treatments are applied directly to the affected skin and can be effective in reducing inflammation, scaling, and plaque thickness.

Corticosteroids:

Corticosteroids are the most commonly prescribed topical treatment for plaque psoriasis. They work by reducing inflammation and slowing down the overproduction of skin cells. Available in various strengths (from mild to very potent), corticosteroids are chosen based on the severity and location of the plaques. Mild corticosteroids are typically used for sensitive areas like the face or groin, while stronger ones are reserved for thicker plaques on areas like the elbows and knees. Long-term use of potent corticosteroids can lead to side effects such as skin thinning, so they are usually prescribed for short periods.

Find out more about corticosteroids here.

Vitamin D Analogues:

Vitamin D analogues help slow the growth of skin cells. They are often used in combination with corticosteroids for enhanced efficacy. These treatments can reduce plaque thickness and scaling and are generally well-tolerated. However, overuse can lead to side effects like skin irritation and elevated calcium levels in the blood.

Find out more about Vitamin D analogues here.

Coal Tar:

Coal tar is one of the oldest treatments for psoriasis. It helps reduce scaling, itching, and inflammation. Coal tar is available in various forms, including shampoos, creams, and ointments. While effective, it has a strong odour and can stain clothing and bedding, which limits its use for some patients.

Find out more about coal tar here.

Salicylic Acid:

Salicylic acid is a keratolytic agent that helps remove the scales associated with psoriasis. It is often combined with other topical treatments to enhance their penetration and effectiveness. Salicylic acid is commonly found in shampoos, creams, and ointments. However, its use should be monitored, as overuse can cause skin irritation and systemic absorption leading to toxicity.

Find out more about salicylic acid here.

Emollients and Moisturizers:

While not a primary treatment for plaque psoriasis, emollients and moisturizers play a critical role in managing the condition. They help keep the skin hydrated, reduce dryness, and prevent the cracking of plaques. Regular use of emollients can also enhance the effectiveness of other topical treatments by improving skin barrier function.

Find out more about emollients and moisturizers here.

2. Phototherapy

Phototherapy, or light therapy, is an effective treatment for moderate to severe plaque psoriasis. It involves exposing the skin to ultraviolet (UV) light under medical supervision.

UVB Phototherapy:

UVB phototherapy involves exposing the skin to ultraviolet B light. Narrowband UVB is the most common form used and is considered more effective than broadband UVB. UVB phototherapy slows the growth of affected skin cells and reduces inflammation. Treatment is typically administered in a controlled clinical setting, two to three times per week, for several weeks. It is often used when topical treatments are not sufficient.

PUVA Therapy:

PUVA (psoralen and UVA) therapy combines the administration of a photosensitizing drug called psoralen with exposure to ultraviolet A (UVA) light. Psoralen increases the skin’s sensitivity to UVA, making the treatment more effective. PUVA is generally used for more severe cases of psoriasis that do not respond to UVB therapy. However, it carries a higher risk of side effects, including an increased risk of skin cancer with long-term use.

3. Systemic Treatments

Systemic treatments are used for moderate to severe plaque psoriasis that has not responded to topical treatments or phototherapy. These medications work throughout the body to reduce inflammation and control the immune response.

Methotrexate:

Methotrexate is an immunosuppressant that slows down the rapid growth of skin cells and reduces inflammation. It is typically taken once a week in pill form or as an injection. Methotrexate is effective for treating both skin and joint symptoms in patients with psoriatic arthritis. However, it can have serious side effects, including liver damage and bone marrow suppression, so regular monitoring is required.

Cyclosporine:

Cyclosporine is a powerful immunosuppressant that can provide rapid relief from severe psoriasis symptoms. It works by suppressing the immune system and reducing inflammation. Cyclosporine is usually prescribed for short-term use due to its potential for significant side effects, including kidney damage and increased blood pressure.

Acitretin:

Acitretin is an oral retinoid (a derivative of vitamin A) that helps normalize the growth of skin cells. It is particularly effective for treating pustular and erythrodermic psoriasis, although it can also be used for plaque psoriasis. Acitretin is often used in combination with phototherapy. However, it can cause side effects such as dry skin, hair loss, and elevated lipid levels, and it is contraindicated in women of childbearing age due to its teratogenicity.

4. Biologic Medications

Biologic medications represent a newer class of treatments specifically designed to target the underlying immune processes that drive psoriasis. They are typically reserved for moderate to severe cases that have not responded to other treatments.

Tumor Necrosis Factor (TNF) Inhibitors:

TNF inhibitors, such as adalimumab (Humira), infliximab (Remicade), and etanercept (Enbrel), work by blocking tumor necrosis factor-alpha, a cytokine that promotes inflammation in psoriasis. These biologics are highly effective in reducing psoriasis symptoms and are also used to treat psoriatic arthritis. However, they can increase the risk of infections and other immune-related conditions, so patients are carefully screened before and during treatment.

Interleukin Inhibitors:

Interleukin (IL) inhibitors target specific cytokines involved in the inflammatory process of psoriasis. Examples include:

IL-12/23 Inhibitors: Ustekinumab (Stelara) targets both IL-12 and IL-23, which are involved in the immune response that causes psoriasis. It is administered via subcutaneous injection and is effective in reducing plaque thickness and inflammation.

IL-17 Inhibitors: Secukinumab (Cosentyx) and ixekizumab (Taltz) inhibit IL-17, a cytokine that plays a central role in the inflammation seen in psoriasis. These medications are particularly effective in treating both plaque psoriasis and psoriatic arthritis.

IL-23 Inhibitors: Guselkumab (Tremfya) and risankizumab (Skyrizi) specifically target IL-23, another cytokine involved in psoriasis. These biologics have shown excellent efficacy in clearing skin plaques and maintaining long-term control of the disease.

T-Cell Inhibitors: Alefacept (Amevive) was the first biologic approved for psoriasis that worked by inhibiting T cells, which are critical in the development of psoriasis plaques. However, it has been discontinued in some markets due to its limited efficacy compared to newer biologics.

5. Combination Therapy

In many cases, a combination of treatments is more effective than using a single therapy alone. Combination therapy can involve using two different topical treatments, combining topical treatments with phototherapy, or using systemic medications in conjunction with biologics. The goal is to maximize the benefits of treatment while minimizing side effects. For example, combining a topical corticosteroid with a vitamin D analogue can provide better control of plaque psoriasis than using either treatment alone.

6. Lifestyle and Home Remedies

While medical treatments are the cornerstone of psoriasis management, lifestyle changes and home remedies can play a supportive role in managing symptoms and reducing the frequency of flare-ups.

Moisturizing Regularly:

Keeping the skin well-moisturized is crucial for managing plaque psoriasis. Regular use of emollients and moisturizers helps prevent dryness and cracking, which can exacerbate symptoms. Products with urea, lactic acid, or ceramides are particularly beneficial for maintaining skin hydration.

Bathing and Soaking:

Regular bathing in lukewarm water with added bath oils or colloidal oatmeal can help soften plaques and reduce itching. Dead Sea salt baths are also popular for their potential benefits in reducing scaling and inflammation. After bathing, it’s important to apply moisturizer immediately to lock in moisture.

Avoiding Triggers:

Identifying and avoiding triggers such as stress, smoking, alcohol consumption, and certain medications can help reduce the frequency and severity of flare-ups. Stress management techniques, including mindfulness, yoga, and meditation, can also be beneficial.

Diet and Nutrition:

While there is no specific diet for psoriasis, maintaining a healthy diet rich in fruits, vegetables, whole grains, and lean proteins can support overall health and potentially reduce inflammation. Some patients find that avoiding certain foods, such as gluten or dairy, helps manage their symptoms, though more research is needed to confirm these effects.

Sun Exposure:

Moderate sun exposure can help improve psoriasis symptoms due to the UV light’s effects on skin cells. However, it is important to balance sun exposure to avoid sunburn, which can trigger a Koebner phenomenon (new psoriasis lesions at sites of skin injury). Sunscreen should be applied to unaffected areas to protect the skin from UV damage.

Stress Management:

Stress is a well-known trigger for psoriasis flare-ups. Incorporating stress management techniques such as deep breathing exercises, yoga, meditation, or engaging in hobbies can help reduce stress and, in turn, reduce the frequency and severity of flare-ups.