Treatments aim to reduce inflammation and scale, slow the growth of skin cells, and remove plaques. Psoriasis treatments fall into several categories: topical treatments, phototherapy (light therapy) and systemic medications (oral or injectables). Some patients also find alternative and complementary therapies that they find helpful, which should be discussed with your doctor.

There is a psoriasis decision aid to help you consider which treatment is best for you. This can help prepare you for this conversation with your healthcare provider

Topical medications

For people living with psoriasis, about 80-90% are considered mild to moderate, and especially mild cases can often be treated with topical agents—treatments applied on the skin. Topical agents may be used alone or in combination with other therapies, such as phototherapy or systemic medications. Topical psoriasis treatments include:

• Topical corticosteroids (i.e., betamethasone, hydrocortisone)
• Topical calcineurin inhibitors 
• Vitamin D analogues/derivatives (i.e. calcipotriol, calcitriol)
• Topical retinoids (i.e., tazarotene) 
• Anthralin
• Salicylic acid
• Moisturizers
• Coal tar

Dosage Form Considerations

Only apply occlusive dressings over topical therapies as instructed by your dermatologist.  This can increase the absorption of the medication and therefore increase its effect however it can also increase the risk of side effects so should be done under supervision of a physician.

Learn more about using topicals to treat psoriasis.

Phototherapy (light therapy)

Phototherapy is the use of ultraviolet light (UV) as a form of treatment. Several different forms of light treatment for psoriasis are available, including exposure to natural sunlight when conditions permit.

The goal of phototherapy is to expose your affected skin to UV light. It is used to treat psoriasis especially when the psoriasis is too widespread to be treated reasonably with topicals. Both UVA and UVB light may be helpful in reducing symptoms of psoriasis. UVA is most often used in conjunction with a photosensitizing drug called psoralen; a treatment called PUVA (Psoralen Ultra-Violet A) light therapy.

Phototherapy is NOT suitable for individuals with a light-sensitive disease, an allergy to the sun,  and in some cases for those taking highly photosensitizing medications. Long term, repeated exposure to UV may cause premature aging of the skin and theoretically can increase the risk of skin cancer. 

Many medications, cosmetics and herbal remedies can increase the skin’s sensitivity to ultraviolet radiation. If using any such products, consult your physician before UV phototherapy. The eyes should be protected from ultraviolet light by wearing UV-blocking goggles as chronic UV exposure can increase the risk of glaucoma and cataracts. 

Phototherapy treatments are available at doctors’ offices, phototherapy clinics or at home. If phototherapy is received in a doctor’s office, it is covered as part of medicare. If you are interested in using phototherapy at home, not all private insurance plans will cover a home phototherapy machine. However, if you have a health spending account, you may have coverage. 

Systemic medications

Systemic treatments are delivered orally (in tablet or liquid form) or through injection or intravenous infusion.

People with moderate to severe psoriasis, and those who have not responded well to other treatment types, may need to use systemics. The medications include:

• Methotrexate
• Cyclosporine
• Acitretin
• Apremilast
• Biologics

Learn more about using systemics to treat psoriasis. 

Biologics

Biological response modifiers or biologics are considered a highly effective treatment option for patients with moderate to severe psoriasis. A biologic is a protein-based drug that is produced from living cells. Biologics can be used on their own or combined with topical or systemic medications. 

Most biologics are currently given by injection just under the skin (subcutaneous injection) and can be administered by a nurse or by the patient themselves after proper training. Some treatments are given by intravenous (IV) infusion at a day clinic or hospital under medical supervision.

Biologics are generally divided into groups based on how they work:

TNF-alpha inhibitors: 

Tumour necrosis factor (TNF) is a signalling molecule that causes inflammation and skin damage in people with psoriasis. Biologics that block TNF-alpha are called TNF-alpha inhibitors.

Interleukin inhibitors:

Interleukins are a proteins that function as messengers of the immune system and can promote inflammation. Interleukins such as IL-17, IL-23, and IL-12 are thought to play an important role in the development of psoriasis. Biologics that target one of these factors can improve skin clearance and reduce symptoms in people with moderate to severe psoriasis. 

To see how these fit together to form the inflammation that causes psoriasis, and which biologics work on these processes, see Psoriasis and Inflammation.

Biosimilars

A biosimilar (also referred to as a subsequent entry biologic) is a similar but not identical version of a biologic (also called a reference or originator biologic). Biosimilars become available once the patent for the reference drug has expired. The originator drug is the first of its kind and as such, its developers get to be the sole manufacturer for a certain length of time. Once that time is up, others are permitted to sell biosimilars, which are similar to the originator but not exactly the same. It is impossible to make an identical copy of a biologic due to its complexity, but we can make very close approximations. Additional testing and research are done on biosimilars to ensure that they are just as safe and effective as the originator. 

Learn more about using biologics to treat psoriasis.  

Biologic medications can be expensive, so most manufacturers have patient support programs (PSPs) that help people access their drug. PSPs can help you navigate insurance, reduce medication costs, and obtain coverage for their drugs. 

Learn more about patient support programs (link).

Alternative and complementary therapies

More than 70% of Canadians regularly use alternative and complementary therapies such as vitamins and minerals, herbal products, homeopathic medicines and other natural health products to stay healthy and improve their quality of life¹.  There is no definitive evidence that these therapies can help psoriasis, but everyone is unique.  If you are interested in complementary or alternative therapies, talk to your doctor to make sure that what you are considering won’t make your psoriasis worse.

Healthy Diet: Many scientific studies have shown that a balanced, low-fat diet can improve your health and prevent many serious illnesses. Healthy eating can also improve your general well-being. Some experts believe that psoriasis may cause nutritional deficiencies in protein, folates (related to medication), water and calories. Correcting deficiencies may help to improve your overall health.

Acupuncture:  Currently, there are no clinical studies that shows that acupuncture is effective for psoriasis. Despite this, if you go this route, choose your practitioner carefully. Look for a trained, certified acupuncturist. Make sure that only single-use, sterile needles are used to avoid transmittable diseases such as hepatitis or HIV.  As there is no evidence that this can help psoriasis, if you are not seeing benefit then consider stopping acupuncture treatments.

 Herbal supplements:  Some herbal supplements can change how other medications work.  There may be weak evidence for benefit from some herbal remedies.  Before taking supplements, check with your doctor or pharmacist and do not exceed the product’s recommended doses as they can cause significant harm. 

References

¹Health Canada, About Natural Health Products  

 Dosage Form Considerations

Lucinda Buhse, Richard Kolinski, Benjamin Westenberger, et. Al. Topical drug classification, International Journal of Pharmaceutics, Volume 295, Issues 1–2, 2005, Pages 101-112, ISSN 0378-5173, https://doi.org/10.1016/j.ijpharm.2005.01.032