When considering medical treatment for psoriasis, your doctor will generally consider the following factors:
- What kind of psoriasis you have, whether it is mild, moderate or severe.
- Your overall state of health.
- How much psoriasis affects the quality of your life.
Sometimes a medical doctor will get you to complete a questionnaire to see how much psoriasis is affecting your life. The mildest skin treatments are used first, and if these are not effective then a stronger treatment is recommended. With moderate to severe kinds of psoriasis, one of the five treatments on this page may be recommended. With certain cases, various combinations of treatment are recommended including ultraviolet light, injections, creams, ointments and tablets.
1 – Coal Tar
Coal tar and pine tar have been used for many years for psoriasis, it is an old therapy dating back to the 1920’s. Tar preparations are generally most useful for scalp psoriasis and chronic plaque form of psoriasis. It works by way of reducing the itching and inflammation, helping to thin down the rough lesions that develop.
I’m personally not a big fan of this kind of treatment, in its most effective form it is a messy and smelly treatment, most patients I know who have tried it have discontinued it due to the smell.
Refined coal tar is readily available in various cream, ointment, gel and stick bases. It isn’t suitable for everyone because it can sting or even aggravate the psoriasis. It tends to be messy to use and many patients dislike the smell. Some people combine it with Vaseline or other forms of petroleum jelly. Be careful NOT to apply coal tar preparations prior to going into the sun, as it may cause sunburn, because the ultraviolet light may cause contact photosensitivity dermatitis. If you are going to consider this therapy, please read the booklet – Psoriasis, What To Do With Your Skin, I wrote about Coal Tar in its natural form, from the pine tree.
2 – Dithranol
Dithranol (also called anthralin) is derived from synthetic drug Chrysarobin. This drug has been around for almost as long as Coal Tar, since the early 1930’s. It works by reducing the skin cell turn-over and can be even more effective than Coal Tar. Unfortunately, it too has a major drawn back as it also tends to be a messy preparation that stains skin, bath and clothing a purplish brown color that does not wash out easily.
It can be very irritating when used on unaffected skin and is unsuitable for those with fair skin. Dithranol should not be used on sensitive skin, the face or in the body’s folds or creases.
This product was originally designed to be left on overnight, and the affected parts that were treated were to be covered with bandages. Today we use if for less greater periods of time with equal effectiveness, and it is best used for very short periods of time only, i.e; “short contact”, for 10 to 60 minutes maximum.
3 – Topical Corticosteroids
Did you know that your body makes it own steroid hormones? The powerful steroid called cortisol is produced by your adrenal gland, and it helps to regulate an incredible amount of processes in your body, including your reaction to stress. Cortisol has a most profound effect of your white blood cells, it helps to activate and empower them.
Corticosteroids are a synthetic version of these naturally produced hormones, and are readily prescribed in creams, ointments and pills. There is no doubt, steroid creams do work and they are effective in many cases, they allow damaged skin to heal and can help to relieve symptoms. They are easy to use, are clean and don’t smell like those other preparations we mentioned before.
Psoriasis patients often prefer to use topical steroids as these are easy, clean, and have a soothing action. Steroidal drugs are useful for treating flexural forms of psoriasis, and have a rather limited action I find with plaque and scalp forms of psoriasis. They are also used frequently for psoriasis affecting the palms and soles. Topical steroid lotions may also be recommended by your doctor to be placed under affected nails for onycholysis (nail psoriasis).
For severe forms of plaque psoriasis, a dermatologist may even offer an intralesional steroid injection, a steroid injection used to reduce the thickened plaques of psoriasis.
You will find that weak topical steroids (often in combination with an antifungal drug) may improve flexural psoriasis but the plaque psoriasis and psoriasis that affects the palms and soles will require stronger topical steroids.
Stronger topical steroids need to be used with care, extreme care in fact. You will find that the most powerful of all topical steroid preparations are without a doubt the most effective, but these drugs also tend to have the highest risk of side effects.
They should be used with a great deal of caution, particularly on large areas of skin and preferably for limited periods because:
- They can trigger other forms of psoriasis if stopped suddenly.
- They can result in long-term aggravation of psoriasis.
- They may thin the skin, causing broken capillaries and stretch marks.
- They are an incredible amount of side effects if used excessively.
You can reduce your risk of side effects if you apply them for no more than two weeks continuously out of every eight weeks, or use them for two consecutive days in each seven-day (weekly) cycle. Side effects are much more likely in the elderly and children, both who are particularly at risk from steroid overuse because their skin is thinner and more absorbent. Some experts feel that children should not receive steroids for asthma, eczema, psoriasis or other immune-mediated conditions because it may interfere with their growth and development.
The big problem with topical corticosteroids is this, they don’t cure your psoriasis, they suppress the symptoms, and this symptom suppression comes at a cost. As soon as you stop taking these steroid drugs, the symptoms come back with vengeance, and in some cases the psoriasis may even come back as another kind or a more severe form of psoriasis.
There is a danger of using corticosteroids continuously for long periods of time. Because steroids reduce inflammation by blocking aspects of your immune system, they are also known to interfere with the body’s ability to heal itself, thus slowing down the skin’s innate healing response. This increases reliance on steroids and leaves the body wide open to infections. Corticosteroids are also drugs that consume Vitamin D, potassium and zinc, important nutrients the body requires to power up the immune system. Corticosteroids trick your body’s adrenal glands into producing less cortisol that help us cope with stress. And because we now know that stress is one of the leading psoriasis triggers, corticosteroid use is particularly damaging to the body.
Corticosteroid drugs have been linked with stomach ulcers, wasting of the muscles, thinning of the skin and many additional skin disorders, water retention, rapid and unwieldy weight-gain, bone disintegration (osteoporosis), a marked increase risk of viral, bacterial and fungal infections, loss or irregularity of menstrual periods, headaches, diabetes, growth retardation, manic depressive and other neurological, mental and psychological disturbances. Are you still interested in these kinds of drugs long term?
Because of these known side effects, steroids are generally only prescribed short term, but psoriasis users know from experience that when the steroids are stopped, that symptoms return, many will continue to use these corticosteroid applications for years, and indeed, and most always written repeat prescriptions for them. My recommendation is to never begin using topical corticosteroids in the first place, avoid them and use natural solutions on your skin instead, you can read all about them in my booklet entitled Psoriasis, What To Do With Your Skin.
4 – Vitamin D-Like Compounds
The most common form of a Vitamin D like compound used is Calcipotriol. The other name it is known as is Daivonex®. This nonsteroidal antipsoriatic cream or ointment is considered one of the safest topical solutions for those with more mild to moderate forms of plaque psoriasis, and is not generally recommended for the more severe and extensive forms. These drugs appear to work by slowing up the development of keratinocytes, the cells that make up the horny layer of epidermis.
Just like topical corticosteroids, calcipotriol does not smell, stain, and is very easy to use. But unlike steroids, long-term use does not seem to have such devastating consequences. Side effects do include local skin irritation and at times an exacerbation of psoriasis. The drug guide I researched stated not to use it on the face, skin folds to use it on the skin and then cover it. Extensively used treatments can increase serum (blood) calcium levels, it is recommended not to use it therefore for any longer than one year without a long break. Irritation is more likely to occur upon first using it (especially the ointment, which is more potent than cream or solution) but this usually lessens with continued use. If irritation does occur, reducing the frequency of application to every second day or less for a period of time usually allows continued use. Discontinue if you feel that the irritation is severe or does not go away after you have stopped it for some time.
Don’t use this ointment on your face; I had one patient complain of a facial rash for many months after she discontinued its use. No more than 100g should be used each week. I always question why doctors like to recommend “derivatives” or synthetic analogues of Vitamins, when they could be monitoring Vitamin D level in your blood. By doing so they can ensure Vitamin stays in the optimal range, so whey should you therefore have to take artificial forms of Vitamin D? It’s just plain crazy.
5 – Calcineurin inhibitors
These kinds of ointments and creams work by suppressing Interleukin 2 (IL-2) produced by your body’s T-Cells, white blood cells. They are also known as TIMs (topical immune-modulators), and powerfully suppress an inflammatory pathway designed by your immune system to counter inflammation in the body. These medications come with very powerful effects on reducing your immune system’s functioning, even more so than topical corticosteroids, and naturally, this come at a huge price, massive side-effects.
Tacrolimus ointment and pimecrolimus cream are both examples of calcineurin inhibitors and both are not registered for use in psoriasis in New Zealand, although this may be different in your country, they are have been registered to use for atopic dermatitis and eczema. They are sometimes used by dermatologists for psoriasis in thin-skinned areas such as face, skin folds and genital areas. For your information, I found this statement on Medscape.com about this class of drugs:
“Patients using calcineurin inhibitors can potentially experience many adverse effects. In general, the number and severity of adverse effects are related to the overall exposure, measured by length of therapy and blood drug concentration. Patients taking cyclosporine may develop high blood-pressure, tremor, kidney toxicity, high cholesterol levels, gum disease, and hirsutism (hair growth on face). Patients receiving tacrolimus may develop high blood-pressure, tremor, many and varied digestive disturbances, kidney toxicity, headaches, liver toxicity, abnormal blood sugar control (diabetes), skin itching, white blood cell toxicity, high potassium levels, and hypomagnesemia. Tacrolimus causes a greater number of and more severe adverse events than does cyclosporine. Dosage reduction may decrease toxicities; however, additional pharmaceutical drugs are often required to counteract the adverse effects of calcineurin inhibitor therapy. The kidney toxicity seen with cyclosporine and tacrolimus is particularly problematic in kidney transplant recipients and may negate a kidney transplant. Calcineurin inhibitor doses are often tapered postoperatively because of such toxicities.” .