Advanced Psoriasis Treatment: When Creams Aren't Enough

For many people, psoriasis plaques don’t improve much after topical treatment with ointments or creams. Sometimes, too much skin has plaques for topicals to be a good option.

Advanced psoriasis treatments are “systemic,” which means they affect the whole body. These can be more effective and convenient than topicals.

At the same time, systemic psoriasis drugs can have more side effects. Knowing the benefits and risks of these treatments can help you and your doctor figure out if they're right for you.

Topical vs. Systemic

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A topical therapy is any psoriasis treatment that’s put on the skin. Absorption into the bloodstream and other effects to your body are minimal.

Common topical treatments include:

  • Corticosteroids (such as hydrocortisone, fluocinonide, or triamcinolone), moisturizers, anthralin, calcipotriene, calcitriol, coal tar, tacrolimus, and tazarotene
  • Ultraviolet light (phototherapy) that focuses only on affected areas of skin

Systemic treatments, working on the entire body, often act on the immune system to ease psoriasis over large areas of the body. These treat moderate to severe psoriasis. Advanced psoriasis treatments include:

  • Oral medications (pills) like acitretin (Soriatane), apremilast (Otezla), cyclosporine, and methotrexate
  • Biologic therapies, including adalimumab (Humira), brodalumab (Siliq), certolizumab pegol (Cimzia), etanercept (Enbrel), guselkumab (Tremfya), infliximab (Remicade), ixekizumab (Taltz), secukinumab (Cosentyx), and ustekinumab (Stelara). These are injectable drugs.
  • Phototherapy, or ultraviolet light treatment to the whole body

While systemic treatments are far more effective than topicals, they can have more side effects. They're also more expensive.

Severity of Psoriasis Is Important

If you're thinking about systemic treatment, think about how severe your psoriasis is. Doctors divide people with psoriasis according to how much skin is affected:

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Mild to moderate or limited psoriasis: Less than 3% of total body surface is affected. (For reference, the palm of the hand is about 1% of your body area.)

Moderate psoriasis: 3% to 10% of your body surface has it.

Severe psoriasis: More than 10% is affected.

A doctors’ rule of thumb: Topical therapies can help limited psoriasis. For moderate to severe psoriasis, putting topical creams to all the skin that's affected may be unrealistic. Most doctors recommend systemic treatment, in that case.

Doctors also often recommend that people still use topical creams, solutions, or ointments while taking systemic treatments. The combination leads to better results than either treatment used alone.

Psoriasis and Quality of Life

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Doctors and people with psoriasis don’t always agree on what’s mild and what’s serious. Psoriasis can affect self-image and make people self-conscious. This can even lead to depression and social isolation.

Only a frank discussion with your doctor about what living with psoriasis means to you will get these issues out in the open.

Making Your Decision

Studies show that many people with limited psoriasis don’t use topicals consistently because the ointments, creams, gels, foams, solutions, and lotions are messy and inconvenient.

Topical treatments haven’t failed them -- they’ve just never been given a chance to work. The first step is to use your topical psoriasis treatment exactly as directed.

Switching to systemic treatment for psoriasis for the sake of convenience isn’t wrong. But you should know the risks and benefits of it first.

Systemic Psoriasis Treatment: Balancing Risks and Benefits

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The fine print on the labels for systemic treatments could give anyone concerns. Most systemic treatments target the immune system. Also:

  • Biologic therapies and some oral treatments can raise the chance of having an infection, so your doctor will monitor you while you are taking them.
  • Phototherapy can cause skin damage, raising your odds of skin cancer.
  • Methotrexate requires monitoring for liver, bone marrow, kidney, and lung damage.
  • Cyclosporine can cause kidney damage and needs to be monitored.

Each treatment has its own side effects, which you should discuss with your doctor.

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