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 and lung examinations may be recommended to look for evidence of 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. It is intended for short-term use.
- 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.
- Apremilast (Otezla): This is an oral medication that has been approved for use in psoriasis. Diarrhea is a frequent side effect of this medication. This medication does not require regular blood tests.
Biologics for Psoriasis
The following drugs are categorized under the term biologic because they are all proteins produced in the laboratory by industrial cell culture techniques and must be given either subcutaneously or intravenously. The frequency of treatment depends on the specific drug. All of these medications are very precise in that they block only one or two parts of the inflammatory reaction and are moderately immunosuppresive. Biologics are rather expensive and do not cure psoriasis but as a group are quite effective and reasonably safe. If it is decided to start a patient on a biologic drug, the choice will depend on the particular physician's expertise, as well as insurance coverage and payment issues.
- Etanercept (Enbrel): This is the first drug that the FDA approved for treating psoriatic arthritis. It is a manufactured protein that works with tumor necrosis factor (TNF) in order 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.
- Secukinumab (Cosentyx): It is an antibody that acts as an interleukin 17 (IL-17) antagonist and, after a loading dose, is administered monthly. IL-17 is another substance that promotes an inflammatory reaction.
- Ixekizumab (Taltz) is an antibody that inhibits IL-17 with a similar mode of action to secukinumab.
- Brodalumab (Siliq) is another antibody that inhibits interleukin-17 receptor A (IL-17RA).
- Guselkumab (Tremfya) is another antibody that inhibits IL 23.
Medically Reviewed by a Doctor on 9/19/2017
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