From pizza toppings to emergency exits, it is important to know your options. For psoriatic disease treatments, there are more options now than ever before. As research into the mechanisms behind psoriasis and psoriatic arthritis (PsA) has uncovered new avenues for treatment, modern technology has allowed for the rapid development of those treatments. Many treatments have come onto the market in the past decade, and many more are coming down the line.
Effective treatments for psoriasis range from topicals and phototherapy to biologics and oral systemics, with complementary medicine playing a supportive role as well. Some treatments can be combined too, so it can easily get overwhelming.
G. Michael Lewitt, M.D., a board-certified dermatologist from the Illinois Dermatology Institute and a member of the National Psoriasis Foundation (NPF) Medical Board, can help make sense of it all. Dr. Lewitt notes that there is more to psoriasis than meets the eye because the visible lesions on the skin are not the full story. Under the skin, inflammation throughout the body is putting you at risk of developing related conditions, called comorbidities. Treating psoriasis above and below the skin is essential, because the comorbidities of psoriasis include high blood pressure, type 2 diabetes, and PsA, among others.
If you are newly diagnosed with psoriatic disease, the typical first line of treatment is one or more topical medications. Topicals include creams and ointments that are applied to the affected skin. You may already have tried over-the-counter (OTC) topicals, such as lotions or shampoos.
Prescription topicals come in two types, either with or without steroids. As anti-inflammatory agents, steroids are the most common topical treatment, and they are available in a wide array of potencies. Nonsteroidal topicals include vitamin D analogs and a retinoid, which is derived from vitamin A. 
Phototherapy (Light Therapy)
Another frontline treatment is phototherapy, where the affected skin is exposed to measured amounts of ultraviolet light, including ultraviolet light A and ultraviolet light B (UVB). Just as some people experience reduced lesions in the sunnier months, phototherapy can decrease the visible effects of psoriasis. However, as Dr. Lewitt notes, both topicals and phototherapy are thought to work mostly on the surface of the skin. They don’t necessarily treat the underlying inflammation, making these treatment options only part of the equation.
Also in this category is the excimer laser, which emits a high-intensity beam of UVB. It may be a particularly effective treatment for scalp psoriasis. However, there is not yet enough long-term data to indicate how long improvements will last following a course of laser therapy. 
Biologic Systemic Treatments
Newer to the scene are biologics, which are made using living organisms. Most biologics for psoriasis are given by injection or infusion and target various proteins, receptors, and cells involved in the immune system that play a role in the development of psoriasis, such as tumor necrosis factor or interleukin-12, IL-23, and IL-17. Compared with traditional systemics, biologic treatments are much more specific in their targeting of the immune system while still treating the systemwide inflammation from psoriasis.
Additionally, biosimilar medicines are a type of biologic drug. Although biosimilars are modeled after an FDA-approved biologic medicine or biologic, they undergo different approval processes. The FDA can approve a treatment as a biosimilar or an interchangeable biosimilar. Several biosimilars have been approved by the FDA; however, your health care provider may not be able to prescribe these treatments yet. There are other biosimilars currently being developed and tested. These may be approved and available in the near future. 
Occasionally, individuals with psoriasis will not be able to clear all of their lesions with one type of treatment. In this scenario, Dr. Lewitt sometimes suggests combination therapy. This means using treatments together to achieve the desired result. It may involve receiving a biologic injection in addition to applying topicals or receiving phototherapy. If biologics are not an option, topicals and phototherapy still can be used together, he says.
Oral Systemic Treatments
As the name suggests, these are systemic treatments that are taken orally (by mouth). Traditional oral systemic psoriasis drugs have been around for more than 10 years. They impact the entire immune system. Newer oral systemic treatments selectively target molecules inside immune cells.
Some treatments are also disease-modifying antirheumatic drugs (DMARDs). DMARDs may relieve more severe symptoms and attempt to slow or stop joint and tissue damage and the progression of psoriatic arthritis. 
Making It Work
Ideally, once you have found an effective treatment option, you will be able to stay on it indefinitely. Sometimes treatments can lose efficacy, however, resulting in flares between doses. Or a treatment is not able to reach the treatment goals.
Adverse effects also are possible. For example, topical steroids can cause thinning of the skin if they are used for extended periods of time.
There also may be mitigating factors such as a change of insurance or a change of coverage for the treatment option. Any one of these reasons is sufficient cause to investigate new treatment options.
In addition, just because all of these treatments are used for psoriasis does not mean each is appropriate for every person who is affected by the disease. As a prescriber, Dr. Lewitt says a number of factors go into choosing treatments, including medical history, the extent of the disease, and specifics such as patient bloodwork and other medications. Importantly, Dr. Lewitt also takes into consideration the person’s preferences and their comfort with the various types of treatment, along with treatment costs in some situations.
Dr. Lewitt says he works with the individual’s specific goals for treatment and also considers logistics, such as someone’s ability to be given regular injections or receive phototherapy sessions at a medical office. He also cautions patients to remember the systemic nature of the disease: Although a few small lesions may not seem worth treating, psoriasis is still busy under the skin causing unknown amounts of harm.
The systemic inflammation of psoriasis is associated with a number of comorbidities. Reducing inflammation through treatment also may reduce the risk of cardiovascular disease, depression, anxiety, PsA, and more.
Because of the higher risk of these comorbidities for people with psoriasis, Dr. Lewitt says it is important to treat the whole person. “I say it to every patient with psoriasis, whether they have a dime-sized plaque or 90% of their body covered,” he says. “Make sure you’re seeing your PCP [primary care provider] once a year. Make sure you’re getting your blood pressure and cholesterol checked, eating right, exercising, minimizing alcohol.”
A patient’s health is a team effort, he says, likening it to a football team with the PCP as the quarterback and family members, caregivers, mental health professionals, and others as players on the squad.
Taking the football metaphor a little further, think of the person with psoriasis as the coach. “When you go to the doctor, you are your own best advocate,” says Dr. Lewitt. Come prepared and ask questions. “Use good resources like the NPF Patient Navigation Center to find the resources you need,” he adds.
Be sure to explain to your physician how your psoriasis is affecting your life, as each person’s experience is different, and it can have an impact on treatment choices and targets. Although you might have only a single lesion, if it is on the scalp, hands, feet, or genitals, it can have an outsized impact on your quality of life.
Dr. Lewitt points out that providers should also keep up to date on the latest advice and treatment options. “There are a lot of great resources that don’t take a lot of time – for example, NPF [continuing medical education] podcasts,” he says.
He encourages people impacted by psoriasis to make sure they find the right provider. Not all doctors are experts in inflammatory diseases that impact the skin and joints, so seek out one who is. And once you find that right fit, follow up, set goals together, and speak up if your goals are not being met.
Topical OTC products that contain keratolytics, such as salicylic acid or urea, can help remove the excess layers of skin on lesions, says Dr. Lewitt. But he warns against exfoliating products because they may injure the skin and increase lesion severity, an effect known as the Koebner phenomenon.
Of course, “it’s always a good idea to ask your provider before starting [any OTC treatments],” Dr. Lewitt says. Be sure to tell your provider about anything that may relate to your health, including using topicals, oral systemic treatments, or complementary medicine. “If it’s a new visit, let them know what you’ve tried, what worked, what didn’t work,” he says.
Ultimately, your journey will be your own, and what works for others may not work for you. Psoriasis is a complex disease, Dr. Lewitt says, adding that “stressors of the heart, the mind, and the body can lead to exacerbations, and it’s an unpredictable course.”