Systemic Medications for Psoriasis
Systemic Medications (Those Taken by Mouth or Injection)
- Psoralens: Methoxsalen (Oxsoralen-Ultra) and trioxsalen (Trisoralen) are commonly prescribed drugs called psoralens. Psoralens make the skin more sensitive to light. These drugs have no effect unless carefully combined with ultraviolet light therapy. This therapy, called PUVA, uses a psoralen drug with ultraviolet A (UV-A) light to treat psoriasis. This treatment is used when psoriasis is severe or when it covers a large area of the skin. Psoralens are taken by mouth one to two hours before PUVA therapy or sunlight exposure. They are also available as creams, lotions, or in bath soaks. More than 85% of patients report relief of disease symptoms with 20-30 treatments. Therapy is usually given two to three times per week, with maintenance treatments every two to four weeks until remission. Adverse effects of PUVA therapy include nausea, itching, and burning. These drugs cause sensitivity to sunlight, risk of sunburn, skin cancer, and cataracts and for this reason, the prescription of the medication for home use with natural sunlight is strongly discouraged.
- Methotrexate (Rheumatrex, Trexall): This drug is used to treat plaque psoriasis or psoriatic arthritis. It suppresses the immune system and slows the production of skin cells. Methotrexate is taken by mouth (tablet) or as an injection once per week. Women who are planning to become pregnant or who are pregnant should not take this drug. The doctor will order blood tests to check your blood cell count and liver and kidney function on a regular basis while on this medicine. After the patient has been on the medication for several years, a liver biopsy may be recommended to look for evidence of liver damage that was not apparent on routine blood tests.
- Cyclosporine (Sandimmune, Neoral, Gengraf): This drug suppresses the immune system and slows the production of skin cells. Cyclosporine is taken by mouth two or three times a day. A doctor will order tests to check your kidney function. Cyclosporine may increase the risk of skin cancer, infection, or lymphoma, and it may cause damage to the kidneys, producing high blood pressure.
- Acitretin (Soriatane): This drug is an oral retinoid, or a modified vitamin A molecule. It does not appear to be as effective as methotrexate or cyclosporine in the treatment of plaque psoriasis, but it works for pustular psoriasis and in other patients with predominantly hand and foot psoriasis. In women of childbearing age, acitretin must be used with caution because of the risks of birth defects. Furthermore, because of the long time needed for the elimination of acitretin from the body, even after treatment is stopped, women must continue to avoid pregnancy for three years. Regular blood tests are required while taking this medication. Side effects include dryness and irritation of the skin, lips, eyes, nose, and mucous membrane surfaces. Other adverse side effects include thinning hair, elevation of cholesterol and triglyceride levels, liver toxicity, and bone changes. Do not donate blood while taking Soriatane and for two years after stopping it.
- Etanercept (Enbrel): This is the first drug that the FDA approved for treating psoriatic arthritis. It is a manufactured protein that works with the immune system to reduce inflammation. Etanercept is given as an injection two times per week initially and then decreased to weekly in most patients. The drug can be injected at home. Enbrel affects your immune system and is especially hazardous to someone with untreated tuberculosis (TB) exposure or a history of hepatitis B. In both of these cases, patients receiving etanercept or any of the other "biologics" discussed below may experience a severe and life-threatening reactivation of their previously quiet disease. Etanercept is rarely associated with heart failure. Like other medicines of the "biologic" family, any use in patients with known or suspected multiple sclerosis (MS) or other demyelinating diseases is done only after careful consideration of other options and with very careful monitoring.
- Adalimumab (Humira): Humira is used to treat moderate to severe chronic plaque psoriasis in adults. It is a protein that blocks TNF-α, a type of chemical messenger in the immune system. In psoriasis, TNF-α overstimulates immune system cells (T cells) and causes psoriatic lesions to develop. Humira is taken by injection under the skin. The recommended dose for adults is one injection every two weeks. Side effects include severe infection, reactivation of TB or hepatitis B, allergic reactions, very rare serious blood disorders, lymphoma, and other cancers.
- Ustekinumab (Stelara): This drug blocks two proteins called interleukin-12 and interleukin-23, which are parts of the immune system. Interleukins-12 and 23 promote the inflammation associated with psoriasis. Stelara is injected under the skin at the start of treatment, after four weeks, and every 12 weeks thereafter. Ustekinumab may potentially increase the risk of malignancy or infection; it also may rarely cause allergic reactions, including skin rash, facial swelling, and difficulty with breathing.
- Infliximab (Remicade): This was one of the original biologic medications used for psoriasis. Advantages are that onset of action is faster than many systemic treatments. Disadvantages are that it must be administered by infusion and, over time, antibodies may develop and decrease its effectiveness.
- Apremilast (Otezla): This medication has recently been approved for use in psoriasis. It seems to be most effective when used in combination with other medications. Diarrhea is a frequent side effect of this medication. Advantages include the fact that it causes less global immune suppression.
- Secukinumab (Cosentyx): This is the most recently approved medication for psoriasis. It is an interleukin 17 (IL-17)antagonist and, after a loading dose, is administered monthly.
- Other medications used primarily for arthritis such as azathioprine (Imuran) or mycophenolate mofetil (Cellcept) sometimes help psoriatic skin disease but are seldom the first choice. Other medications that may be prescribed for arthritis but are not yet approved or have only recently obtained approval by the U.S. Food and Drug Administration (FDA) for skin psoriasis may show significant benefits for the skin disease as well.
Medically Reviewed by a Doctor on 11/30/2015
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