Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
Medications applied directly to the skin are the first course of treatment options. The main topical treatments are corticosteroids, vitamin D-3 derivatives, coal tar, anthralin, or retinoids. For more detailed information on each medication, see Understanding Psoriasis Medications. Generic drug names are listed below with examples of brands in parentheses.
Topical medications
Vitamin D: Calcipotriene (Dovonex) is a form of vitamin D-3 and slows the production of excess skin cells. It is used in the treatment of moderate psoriasis. This cream, ointment, or solution
is applied to the skin two times a day. Calcipotriene combined with the betamethasone dipropionate (Taclonex) flattens lesions, removes scale, and reduces inflammation and is available as an ointment. The suspension form of this medication (Taclonex) is used to treat psoriasis on the scalp. The ointment or suspension is applied once daily to affected areas. Do not apply the medication to normal areas that do not have psoriasis.
Calcitriol ointment (Silkis) contains calcitriol, which binds to the vitamin D receptors on skin cells and reduces the excessive production of skin cells, which helps to improve psoriasis. Calcitriol ointment should be applied to the affected areas of skin twice a day.
Coal Tar: Coal tar (DHS Tar, Doak Tar, Theraplex T) contains literally thousands of different substances that are extracted from the coal carbonization process. Coal tar is applied topically and is available as shampoo, bath oil, ointment, cream, gel, lotion, ointment, paste, and other types of preparations. The tar decreases itching and slows the production of excess skin cells.
Corticosteroids: Clobetasol (Temovate), fluocinolone (Synalar), and betamethasone (Diprolene) are commonly prescribed corticosteroids. These creams or ointments are usually applied twice a day, but the dose depends on the severity of the psoriasis.
Tree Bark Extract: Anthralin (Dithranol, Anthra-Derm, Drithocreme) is considered to be one of the most effective antipsoriatic agents available. It does have potential to cause skin irritation and staining of clothing and skin. Apply the cream, ointment, or paste sparingly to the patches on the skin. On the scalp, rub into affected areas. Avoid the forehead, eyes, and any skin that does not have patches. Do not apply excessive quantities.
Topical retinoid: Tazarotene (Tazorac) is a topical retinoid that is available as a gel or cream. Tazarotene reduces the size of the patches and the redness of the skin. This medicine is sometimes combined with corticosteroids to decrease skin irritation and to increase effectiveness. Tazarotene is particularly useful for psoriasis of the scalp. Apply a thin film to the affected skin every day or as instructed. Dry skin before using this medicine. Irritation may occur when applied to damp skin. Wash hands after application. Do not cover with a bandage.
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 several 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 on an outpatient basis, 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.
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. The drug can be injected at home. Rotate the site
of injection (thigh, upper arm, abdomen). Do not inject into bruised, hard, or tender skin. Enbrel affects your immune system and rarely is associated with heart failure.
Methotrexate (Rheumatrex): 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. Men must not take this drug if there is a possibility that they will impregnate their partners because it can go into the sperm. 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.
Cyclosporine (Sandimmune, Neoral): This drug suppresses the immune system and slows the production of skin cells. Cyclosporine is taken by mouth once a day. Your doctor will order tests to check your kidney and liver function and levels of cyclosporine in your blood while you are on this medicine. Cyclosporine may increase the risk of infection or lymphoma, and it may cause high blood pressure.
Alefacept (Amevive): In 2003, the FDA approved this drug for the treatment of
psoriasis. It suppresses the immune system to slow down the production of skin
cells. Alefacept is given as an injection once per week. Women who become pregnant while taking alefacept should be enrolled in the manufacturer's pregnancyregistry by calling 866-263-8483. Alefacept may increase the risk of malignancy or infection; may cause allergy or swelling of the throat or tongue; and may cause a hard lump, inflammation, or bleeding at the injection site.
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. However, it works for pustular 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 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 the cholesterol and triglyceride levels, liver toxicity, and bone changes. Do not donate blood while taking Soriatane and for two years after stopping it.
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 and is available by prescription only. The recommended dose for adults is
one injection every two weeks. Side effects include severe infection, reactivation of TB or hepatitis B, allergic reactions, 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 weeks 0, 4, and every 12 weeks thereafter. Ustekinumab may potentially increase the risk of malignancy or infection; it also may cause allergic reactions including skin rash, swollen face and difficulty with breathing.
