Psoriasis

Psoriasis Causes and Treatment

Here’s why 2 percent of Americans experience this chronic condition, plus all the time-tested and new treatment options.

Cathy Cassata
By
Ross Radusky, MD
by
treatments for psoriasis
Treatment options for psoriasis include biologic drugs and creams and other topicals made with coal tar.Getty Images (4); Canva; Everyday Health

Researchers continue to investigate why some people develop plaque psoriasis, an autoimmune disease that results in the overproduction of skin cells. These extra cells rapidly pile up on the skin’s surface, forming thick, itchy, dry, discolored patches called plaques.

A better understanding of the causes of psoriasis is helping doctors better treat this chronic condition. (There is no cure.) Plus research insights are leading to new psoriasis medications that can help people who aren’t getting adequate relief from existing drugs.

Psoriasis Causes

Family history can definitely predispose a person to developing psoriasis, but other factors also come into play.

“Genetics seems to play a large role — people with psoriasis often have a family history of psoriasis or psoriatic arthritis,” says Shilpi Khetarpal, MD, a dermatologist at Cleveland Clinic Main Campus in Ohio.

But the role of genes isn’t clear-cut. Some people who develop psoriasis don’t have genes that increase their risk, and some people with genes that are known to increase the risk of developing psoriasis never do, per the American Academy of Dermatology (AAD).

The best explanation: Psoriasis is due to a certain "mix" of genes in combination with environmental triggers, some of which are still unknown.

Note that psoriasis can develop in people of any race or ethnicity, according to the AAD. While individuals can have their first psoriasis symptoms at any age, there are two peaks: between 20 and 30 and between 50 and 60, according to an article in JAMA Dermatology.

Psoriasis Isn’t Contagious

There is no evidence that psoriasis is contagious; it doesn’t spread through physical contact or exchange of bodily fluids. In other words, a person can't spread the disease through touch or saliva or during any kind of sexual contact, per the AAD.

Risk Factors for Psoriasis

While anyone can develop psoriasis, the following factors raise the odds:

Triggers for Psoriasis Flares

Stress is one of the biggest triggers for psoriasis flares. Per the AAD, others include:

Treatments for Psoriasis

Most psoriasis therapies aim to slow down the overproduction of cells, remove scales, and reduce inflammation. Treatment options include topicals (creams and ointments), light therapy (also called phototherapy), and oral or injected drugs (systemic therapy).

The treatment plan for psoriasis depends on many factors, including severity, plaque locations, medications with the best response, and personal preference. Getting it right often takes trial and error, a combination of approaches, or both.

Treating psoriasis can not only help improve symptoms, it can lower the risk of developing other related health conditions, including heart disease, obesity, diabetes, depression, and psoriatic arthritis, according to the NPF. Even with successful treatment, psoriasis often returns, but proper management will reduce the number and severity of flares.

Some treatments have side effects or should not be used along with other medications, or when breastfeeding or pregnant. Make sure you discuss any therapies you are considering, even so-called natural ones, with your healthcare provider.

Topical Psoriasis Treatments

Topical treatments are applied directly to the skin and include lotions, ointments, creams, foams, solutions, sprays, and shampoos. These are usually the first option for treating mild to moderate psoriasis, per Mount Sinai.

Topical Corticosteroids These anti-inflammatory medicines, generally referred to as steroids, are the most frequently used treatments for psoriasis. Topical steroids are made from the natural corticosteroid hormones produced by the adrenal glands and come in various brands and strengths.

Steroids can help control inflammatory responses in the body and reduce symptoms such as swelling, redness, and itch.

Long-term use of powerful steroids can come with side effects such as skin thinning, changes in pigmentation, easy bruising, stretch marks, and dilated surface blood vessels.

Vitamin D Analogues These medications help psoriasis by slowing skin-cell growth. Different types include calcipotriene (Dovonex), calcitriol (Vectical), and tacalcitol. These therapies are effective for some people when used as the sole treatment, though a systematic research review found that vitamin D analogues combined with a topical corticosteroid are more effective than either alone.

Topical Calcineurin Inhibitors (TCIs) Tacrolimus (Protopic) and pimecrolimus (Elidel) are used to treat psoriasis, especially in sensitive parts of the body such as the face or groin. These medications can improve psoriasis rash and reduce scaly buildup, according to Mayo Clinic.

Tapinarof (Vtama) Cream 1 Percent This topical steroid alternative is an aryl hydrocarbon (AHR) receptor agonist; AHR is a protein that has a role in regulating metabolism and immunity. Tapinarof helps control excessive skin cell production, according to the NPF.

Roflumilast (Zoryve) Cream 0.3 Percent This medication is another topical steroid alternative. The only approved topical phosphodiesterase-4 (PDE4) inhibitor, it works by suppressing the immune system, thus reducing inflammation. Roflumilast has been shown to be effective in treating inverse psoriasis, a type of psoriasis that appears in skin folds, per the NPF.

Retinoids A retinoid is a synthetic form of vitamin A; the type that’s used as a topical treatment for psoriasis is called tazarotene (Tazorac). Retinoids can slow the growth of skin cells, reduce thick psoriasis plaques, lessen discoloration and swelling, and treat nail psoriasis, according to the AAD. People who are pregnant or plan to become pregnant within three years should not use these drugs.

Salicylic Acid Often sold over the counter, this medication is a keratolytic (peeling agent) that causes shedding of the outer layer of your skin. In psoriasis, it helps soften and remove scales, per the NPF.

Coal Tar Coal tar topicals come in various formulations and are considered one of the oldest psoriasis treatments, according to the NPF. These topicals contain actual tar that comes from coal and wood (juniper and pine). Like salicylic acid, coal tar medication belongs to a class of drugs called keratolytics or keratoplastics.

By slowing the rapid growth of skin cells, tar can restore the skin’s smooth appearance and help with symptoms like inflammation and itchiness.

Anthralin (Dritho-Scalp, Drithocreme, Micanol) This medication works to slow skin cell reproduction. It is recommended only for chronic or inactive psoriasis, not for active or inflamed flares, according to Mount Sinai.

Light Therapy for Psoriasis

Light therapy, also known as phototherapy, exposes skin to specific types of light. The treatment requires some dedication: A typical course of treatment is two to three times a week for three to four months, for a total of about 24 to 30 sessions, according to the AAD.

Your doctor may suggest one or more of the following phototherapy or combination therapy approaches:

  • Ultraviolet B (UVB) This treatment can be delivered as either broadband UVB (BB-UVB) or narrowband UVB (NB-UVB). UVB phototherapy is a good option for people with moderate to severe psoriasis, patients with plaque psoriasis, those with thin plaques, and people who are generally responsive to natural sunlight.
  • PUVA (Psoralen and Ultraviolet A) For advanced psoriasis, a doctor might recommend combining ultraviolet A light with psoralen, a light-sensitizing medication that is most commonly administered orally. Taken shortly before light treatment, psoralen seems to boost the therapeutic effect of light on the immune system.

Light therapy is administered in a doctor's office or psoriasis clinic, or at home with a phototherapy unit. The FDA regulates medical devices used in the application of phototherapy. One phototherapy device, an excimer laser, can administer highly targeted beams of ultraviolet light to treat select areas of affected skin.

Before starting phototherapy, tell your doctor about any new drugs you are taking. Light therapy may not be recommended for people with certain medical conditions, such as lupus and porphyria, that require avoiding exposure to sunlight.

Minor side effects of phototherapy can include inflammation, itching, or a temporary worsening of symptoms. Patients and doctors should monitor skin closely for suspicious lesions and any other early signs of cancer.

Sunlight Exposure Short periods of exposure to natural sunlight, also called solar therapy or heliotherapy, may help improve psoriasis. But too much sun can lead to flares and increase the risk of skin cancer; talk to your doctor about how much sunlight exposure is safe for your situation. It’s also recommended that you apply sunscreen with an SPF of 30 or higher to all areas of skin unaffected by psoriasis, according to NYU Langone in New York City.

Systemic Therapies for Psoriasis

These treatments target processes inside the body that are causing the psoriasis. Therapies are either oral (by mouth), injected, or intravenous (through an IV), depending on the drug.

Systemic psoriasis therapies are usually reserved for people with moderate to severe disease and include:

Corticosteroids In some cases of severe psoriasis, a dermatologist may prescribe systemic steroids to reduce inflammation, although there is a risk that steroid withdrawal can lead to a pustular flare, per the AAD.

Biologic Medications These drugs are protein-based medicines that are derived from living cells cultured in a laboratory. Biologics work by blocking (inhibiting) the action of a specific type of immune cell and proteins in the part of the immune system that is overactive.

Typically, doctors reserve these medications for people with moderate to severe psoriasis, sometimes prescribing them in conjunction with another medication, such as a topical steroid, according to the AAD. Biologics are generally administered either by an injection into the skin or via intravenous (IV) infusion.

Because biologics work by lowering the immune response, people who take them have an increased risk of developing a serious infection.

Researchers have linked numerous biological pathways to psoriasis, and different biologics target different pathways. Biologics for psoriasis can be grouped according to the inflammatory pathway they inhibit.

Medications include:

IL-12/23 Inhibitors

IL-17 Inhibitors

IL-23 Inhibitors

TNF-Alpha Inhibitors 

Immunomodulators These medications suppress or regulate the part of the immune system that causes the overproduction of skin cells, according to NYU Langone. These biologics include:

Sometimes doctors prescribe drugs off-label for psoriasis, which means the U.S. Food and Drug Administration (FDA) didn’t specifically approve the drug for this purpose. Examples of off-label immunomodulators for psoriasis include:

Complementary Treatments For Psoriasis

Complementary therapies can sometimes improve symptoms of psoriasis. Although most of these approaches are safe, you should talk to your doctor before trying any new treatment or technique.

Examples of complementary methods commonly used to treat psoriasis include:

Diet and Nutrition There is no evidence that eating one particular diet can help manage or prevent psoriasis flares. But after a systematic review of scientific studies on psoriasis and diet, the medical board of the National Psoriasis Foundation published dietary recommendations in August 2018 in JAMA Dermatology.

The authors found strong evidence that adults with overweight or obesity can improve their psoriasis by reducing their caloric intake to support weight loss. They also recommended a gluten-free diet for people with psoriasis who have confirmed celiac disease. For people who test positive for blood markers of gluten sensitivity, the board suggested a three-month trial of a gluten-free diet in addition to standard medical therapy.

Healing Baths A quick soak in mineral water baths may help hydrate and soften psoriatic skin. Adding colloidal oatmeal, Epsom salts, or Dead Sea salts to bathwater may help calm inflamed skin, according to the NPF. But stay away from hot water and harsh soaps, which can worsen symptoms.

Over-the-Counter Topicals Products that contain aloe vera, jojoba, urea, zinc pyrithione, and capsaicin may help relieve itching, moisturize and soothe irritated skin, and remove scales, per the NPF. Be aware that even ingredients billed as natural may cause side effects or reactions.

Mindfulness Mindfulness is the practice of being fully present in the moment and accepting “what is” without judgment; it’s been shown to be effective in managing stress. There is evidence that regularly practicing mindfulness meditation can help manage psoriasis and improve quality of life, according to a systematic review published in Dermatology and Therapy.

Physical Activity A joint guideline review by the Journal of the Academy of Dermatology and the National Psoriasis Foundation recommended that dermatologists counsel their patients on lifestyle changes that include regular exercise in order to reduce the risk of associated comorbidities (diseases that often occur in people with psoriasis) such as metabolic syndrome.

All adults should get 150 minutes of moderate-intensity physical activity per week along with two days of muscle-strengthening exercises, according to the current Physical Activity Guidelines for Americans.

Acupuncture This ancient Chinese practice may relieve psoriasis symptoms. A meta-analysis published in the Journal of Complementary Medicine concluded that acupuncture-related techniques could be considered as part of a treatment plan in the short term, but that more rigorous studies were needed.

Additional reporting by Becky Upham.

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