Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
Catherine Burt Driver, MD, is board certified in internal medicine and rheumatology by the American Board of Internal Medicine. Dr. Driver is a member of the American College of Rheumatology. She currently is in active practice in the field of rheumatology in Mission Viejo, Calif., where she is a partner in Mission Internal Medical Group.
In addition to NSAIDs, your doctor may prescribe other medications. 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. Oral vitamin D is also recommended for both patients with psoriasis and those with psoriatic arthritis.
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 usually is 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.
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. The doctor will order blood tests to check the blood cell count and liver and kidney function on a regular basis while on this medicine.
Etanercept (Enbrel) - This is the first biologic drug approved for treating psoriatic arthritis. It is a manmade protein that works with the immune system to reduce inflammation. Etanercept is given as an injection. 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 the immune system and individuals with significant infections are not to take this drug. It is rarely associated with heart failure.
Adalimumab (Humira) - The FDA approved this drug in 2005 for reducing symptoms of active arthritis in psoriatic arthritis. It is self-administered as an injection every
two weeks. Individuals with active infections are not able to take this drug. It suppresses the immune system. It is rarely associated with heart failure.
Infliximab (Remicade) - This drug was also approved in 2005 for psoriatic arthritis. The drug must be given as a
two-hour intravenous (into the vein, IV) infusion. Initially, the drug is given
three times within six weeks, and then it may be administered every eight weeks. Side effects are similar to adalimumab and etanercept. It suppresses the immune system and individuals with significant infections are not to take this drug. It is rarely associated with heart failure.
Cyclosporine (Sandimmune, Neoral) -
This drug suppresses the immune system and slows the production of skin
cells. Cyclosporine is taken by mouth once a day. The 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.
