Psoriasis is a chronic systemic inflammatory disease that causes the skin cells (keratinocytes) to multiply much faster than usual. The accelerated proliferation of keratinocytes is caused by an abnormal immune system reaction and the presence of chronic inflammation.
The goal of treatment is to control the disease so that it manifests minimally and does not decrease the quality of life. The therapeutic goal is long-term inflammation control.
Treatment depends on the stage of the disease. While topical medications (skin medications) and phototherapy work well in mild stages, systemic treatment (tablets, injections, infusions) is used in more advanced stages.
Topical treatment
The first-line treatment for mild to moderate psoriasis consists of medications for local application, usually in the form of creams, ointments, gels, and the like.
Their goal is to hydrate dry skin, locally suppress inflammation, slow down the formation of skin cells, and soften and remove scales.
The advantage of topical treatment is the minimization of systemic (whole-body) side effects. Getting the medication into the bloodstream from the skin surface is difficult. Auxiliary substances help facilitate penetration through the layers of the skin. Topical medications for psoriasis are not designed to deliver the drug into the blood, so only minimal amounts of the medication reach the bloodstream, reducing the risk of systemic side effects to a minimum.
The disadvantage of topical treatment is its relatively weak efficacy (in disease control) because it acts only on the surface and does not suppress systemic inflammation. Another drawback is the need for daily application, which can be time-consuming and uncomfortable.
Keratolytics
They serve to soften and remove hardened skin and scales while facilitating the penetration of other medications into the skin.
The most well-known keratolytics are:
- salicylic acid (which also has anti-inflammatory effects)
- lactic acid
- urea
Keratolytics are available over the counter and can be commonly purchased at pharmacies. However, they are often used in combination with other medications, in which case they are usually prescription-based.
Ichthammol
Ichthammol is a black viscous liquid obtained from bituminous oil.
This unusual substance has anti-inflammatory effects, relieves itching, and slows down the formation of skin cells. You can find it over the counter in pharmacies in the form of ointment, paste, or shampoo to alleviate psoriasis symptoms in the hair.
Vitamin D derivatives
Vitamin D derivatives used for topical treatment of psoriasis include calcipotriol and tacalcitol. They work by slowing down the formation of skin cells. When combined with corticosteroids, these drugs also have anti-inflammatory effects.
Vitamin D derivatives are available by prescription only.
Vitamin A derivatives (Retinoids)
Topical preparations containing retinoids work similarly to vitamin D derivatives, slowing down the multiplication of skin cells.
Retinoids for the treatment of psoriasis, whether topical or oral (tablets, capsules, etc.), are prescription-based.
Although retinoids can often be found in cosmetics, do not confuse one for the other. Retinoids in anti-aging skincare products have precisely the opposite effect – they promote the formation of skin cells.
Topical corticosteroids
Corticosteroids effectively suppress inflammation and slow down the production of skin cells, making them among the most commonly used medications not only for psoriasis but also for other inflammatory skin conditions such as atopic dermatitis.
There are many topical corticosteroids available on the market in various forms (cream, gel, ointment, foam, shampoo, liquid, emulsion, patch), making application to different body areas easier.
They are classified based on their potency into:
- mildly potent (hydrocortisone – the only one available over-the-counter)
- moderately potent (hydrocortisone butyrate, alclometasone, triamcinolone)
- potent (betamethasone, fluocinolone, mometasone)
- very potent (clobetasol)
In areas with thinner skin (face, armpits, groin, genitals), corticosteroids should only be used short-term and in a thin layer because they can cause skin thinning (atrophy).
Almost all topical and systemic corticosteroids are prescription-based. Apply these preparations only according to the instructions of a doctor or pharmacist.
Calcineurin inhibitors
These substances suppress the immune system through mechanisms similar to corticosteroids. Their effect is not as strong, but they have fewer side effects. Therefore, they may be more suitable for long-term treatment on sensitive body areas.
Phototherapy
Phototherapy uses UVA or UVB radiation. UV light slows down cell multiplication and reduces inflammatory reactions.
- UVB radiation is used in mild to moderate forms.
- UVA radiation penetrates deeper but has more side effects, so it is only used in more severe forms of psoriasis.
A special type of phototherapy is PUVA therapy, where the patient takes psoralen (or bathes in it or applies it to the skin) before UVA radiation, which is a drug that increases the skin's sensitivity to UV light. PUVA therapy is among the most effective types of phototherapy.
The disadvantage of phototherapy is the need to visit the clinic two to three times a week for 8 to 16 weeks. In some countries, it is possible to borrow phototherapeutic equipment and undergo procedures in the comfort of home.
Other disadvantages include accelerated skin aging and mild suppression of the immune system. In the case of PUVA therapy, there is also an increased risk of skin cancer and increased sensitivity to light.
Phototherapy is not suitable for individuals with photosensitive psoriasis, acute sunburn, skin tumors, systemic lupus, active tuberculosis, and also if the person is taking drugs that increase skin sensitivity to light (photosensitizing drugs) or drugs that suppress the immune system.
Systemic treatment of psoriasis
While topical therapy acts only at the site of application, systemic treatment affects the entire system (organism). Systemic therapy is characterized by oral administration (tablets, capsules, etc.) or administration by injection or injection pen.
It is used in cases of moderate to severe psoriasis when local treatment and phototherapy fail to adequately control the condition. It is also prescribed when psoriasis affects the joints and psoriatic arthritis develops.
Although psoriasis may not respond sufficiently to topical treatment, regular hydration, and skin care are important components of treatment at every stage.
Classic systemic treatment
To distinguish between the new type of drugs (biologic drugs) and the older type of drugs, we use the terms classic and biologic treatment.
Classic systemic treatment includes well-known medications such as methotrexate, acitretin, and cyclosporine. Apremilast belongs to the newer substances.
Methotrexate
It is mainly used for treating cancer, rheumatoid arthritis, and psoriasis. It is taken once a week, and regular blood tests are necessary.
Due to its side effects, methotrexate is not recommended for most risk groups. It should not be taken by pregnant or breastfeeding women or by couples planning to conceive a child within six months.
Despite the drawbacks mentioned earlier, methotrexate is effective and helps treat psoriasis which has not responded to topical treatment.
Acitretin
Acitretin belongs to retinoids (vitamin A derivatives). Although the exact mechanism of action is not known, it slows down the division of skin cells, helping to alleviate the symptoms of psoriasis.
Acitretin is usually taken once daily. Among the disadvantages is increased skin sensitivity to light, so direct sunlight should be avoided.
Women must not become pregnant while taking acitretin because the drug can harm the fetus and cause premature birth. If a woman of childbearing age is taking acitretin, she must be informed of the risks to the fetus and the need for contraception before and after treatment.
Cyclosporine
It belongs to immunosuppressants – drugs that suppress the immune system. It is taken twice daily according to the dose prescribed by the doctor, and blood pressure and kidney function should be monitored during treatment.
Like acitretin, cyclosporine increases skin sensitivity to light, so sun protection is necessary when taking it. Phototherapy should not be used during cyclosporine treatment.
**Apremilast **
Apremilast reduces the activity of an enzyme responsible for the inflammatory response. It is one of the newest drugs for psoriasis and is also the safest in conventional systemic treatment.
Biological therapy for psoriasis
Biological therapy is one of the greatest innovations in the field of medicine and pharmacy. Unlike conventional drugs, which are produced synthetically, semi-synthetically, or are of natural origin, biological medicinal products are manufactured in living organisms (yeasts, bacteria).
The greatest advantage of biologics is their selectivity. We are able to precisely target them to the part of the immune system that is causing the problem while leaving other parts unaffected. This achieves targeted therapy, which is usually more effective and safer than conventional systemic therapy.
To start biological treatment, you must first undergo conventional systemic therapy. If it is ineffective, too harmful, or contraindicated, the doctor may suggest biological treatment (if it is suitable for you).
You can find more information about biological therapy for psoriasis on this subpage.
Non-pharmacological options in psoriasis treatment
In psoriasis management, you can also benefit from non-pharmacological therapy. In addition to the already mentioned phototherapy, staying at specialized spas or taking a summer vacation by the sea can also help.
However, these methods are not a substitute for standard treatment recommended by a doctor.
In addition to adhering to treatment, maintaining a healthy lifestyle is crucial for controlling psoriasis. Stress is also a common trigger - you can learn more about this topic (including useful tips on how to manage it) on this subpage.
