Psoriasis and Psoriatic Arthritis

The following medications are most commonly used to treat psoriasis and psoriatic arthritis:

Prescription Topical Therapies

Corticosteroids (e.g., Aristocort, Maxivate, Diprolene, Fluonex, Temovate, and Olux) – are applied to the skin to reduce inflammation. They are often used twice per day early in treatment and then slowly tapered if symptoms improve. Various potencies are available in cream, ointment and lotion formulations, as well as injection form (e.g., Kenalog). Overuse or misuse may result in side effects. Whether or not a person develops these side effects depends on what type of corticosteroids is taken, the dose, the length of time used and how sensitive the individual is to the treatment.

Common side effects from corticosteroids include: skin thinning, osteoporosis, easy bruising, stretch marks, and glaucoma.

Precaution: corticosteroids should be discontinued slowly (tapered) to avoid withdrawal symptoms if taken for longer than a week.

Anthralins (e.g., Anthra-Derm, Miconal)
works by slowing down the growth of skin cells. It is less commonly used as it is thought to be less effective than corticosteroids. It can cause irritation and staining and should only be applied sparingly when prescribed.

Topical retinoids (e.g., Tazarotene)
is derived from vitamin A and is available as a gel or cream. It is usually applied only once per day, in the evening. It may be particularly useful in scalp psoriasis.

Vitamin D analogs (e.g., Calcipotriene)
work by slowing the growth of skin cells in the epidermis and is available in cream, ointment and solution. It can be used with or without corticosteroids. Side effects are usually minimal.


Over-the-counter (OTC) Topical & Oral Therapies

Moisturizers
emollients such as Moisturel, Cetaphil, Curel, and Nivea can help keep moisture in skin and decrease skin flaking. They should be applied immediately after bathing or showering.

Coal Tar Preparations
are often used in combination with other treatments. Estar gel, Balnetar, Neutrogena T/Gel are available in ointment, cream, lotion, shampoo, and bath oil. Although side effects are minimal, coal tar can stain skin, hair, and clothing.

NSAIDs (e.g., aspirin and ibuprofen)
non steroidal anti-inflammatory drugs are prescribed in psoriatic arthritis to help with the joint stiffness and discomfort associated with psoriatic arthritis.


Systemic Therapies – Traditional

Traditional systemic therapies are oral prescription medications that circulate throughout the entire body.

Methotrexate
slows down the rate of skin cell growth in psoriasis. Improvement may not show for 3 to 6 weeks after starting this therapy and maximum improvement may take up to 6 months. Methotrexate is usually taken once a week, either in oral form or by injection. In patients with psoriatic arthritis both the psoriasis and the joints need to be treated. Methotrexate helps with both symptoms and other therapies may also be added by the treating doctor. Some individuals continue on therapy long-term to keep their psoriasis under control. In such patients, regular blood testing and liver monitoring is needed to ensure the drug is being processed safely by the body. While taking methotrexate, many providers recommend taking folic acid 1 mg daily or folinic acid 5 mg weekly to reduce the risk of certain methotrexate side effects, such as upset stomach and a sore mouth.

  • Common side effects include: tiredness, difficulty sleeping, lightheadedness, mouth ulcers (could indicate dose is too high), vomiting, headache, easy bruising and bleeding, fever, chills, diarrhea with blood in stool, sensitivity to light, burning sensation in lesions, and hair loss.
  • Patients with any of the following conditions should not use methotrexate: people suffering from alcoholism, liver disease, immunodeficiency syndromes, pregnant or nursing mothers, men or women attempting a pregnancy, people with active peptic ulcers, significant kidney abnormalities, active infectious disease or pre- existing blood problems, should not take methotrexate.

Acitretin (Soriatane®)
is an oral retinoid, synthetic form of vitamin A that helps regulate the multiplication of skin cells and are indicated for adults with severe psoriasis. The prescribed dose is taken once a day and should be taken with food. It may take up to 16 weeks before improvement occurs and six months before peak effect is reached.

  • Common side effects include: hair loss, chapped lips and dry mouth, dry skin and dry eyes, bleeding gums and nose bleeds, increased sensitivity to sun light, peeling fingertips and nail changes, changes in blood fat levels, depression, aggressive thoughts or thoughts of self-harm, headache, joint pain, decreased night vision, and elevated liver enzymes.
  • Associated risks: pregnant women or breast feeding woman, people with liver or kidney disease, people with high fat levels in the blood, that are not controlled with medications, or people allergic to retinoids, should not take this drug.

Apremilast (Otezla®)
is a newer oral drug that works by reducing inflammation. It can help control symptoms of both psoriasis and psoriatic arthritis.

  • Common side effects include: diarrhea, nausea, upper respiratory tract infection, and headache. Emergence or worsening of depression, suicidal thoughts, or other mood changes may also occur (if any of these symptoms occur, a health care professional should be contacted immediately).
  • Immune modifiers such as cyclosporine, azathioprine, sulfasalazine, or leflunomide may also be used, especially in patients with psoriatic arthritis who have not responded to methotrexate and/or topical therapies. Common side effects are nausea, vomiting, diarrhea, increased risk of infection, decreased white blood cell counts, and liver damage; however, side effects can be serious and vary depending on the medication.

Ultraviolet Light Therapy

Photo therapy is artificial ultraviolet light, or a combination of ultraviolet light and medications used for light therapy where the skin or just psoriasis lesions are exposed to ultraviolet (UVA or UVB rays). This treatment is believed to be highly effective for improving skin symptoms in most patients, but will often require multiple treatment sessions per week. Treatment can be administered in a doctor’s office or sometimes at home.

PUVA-psoralen (a light sensitizing medication) – is an oral medication that can sometimes be combined with exposure to ultraviolet light to help sensitize the skin to treatment. It is not recommended when attempting pregnancy or breast feeding due to reported birth defects.

Long-term risks of ultraviolet light therapy may include increased risk of skin cancer.


Systemic Therapies – Biologics

Biologics are drugs made from living organisms that target specific proteins in the inflammatory process. For example, certain biologics block a substance called TNF-alpha from binding to their body and leading to swelling. Other classes of biologics used for psoriasis and psoriatic arthritis include IL-17 inhibitors and IL-12/IL-23 inhibitors. They are used to treat moderate to severe psoriasis and/or psoriatic arthritis when people don’t respond well to other medications. The medications are injectable and depending on the medication may either be self-administered or administered by a health care professional.

Common side effects include: stomach pain, weakness, decreased white blood cells and platelets, and an increased risk of infections. Call your doctor immediately if you have an infection or fever. Common symptoms of infection include fever, difficulty breathing, or vision changes. Biologic therapies generally should not be used in patients with active serious infections or a history of recurrent infections.

Biologics indicated for psoriasis and/or psoriatic arthritis include:

  • TNF-alpha inhibitors: Cimzia, Enbrel, Humira, Remicade, Simponi, Inflectra
  • IL-12 and IL-23 Inhibitors: Stelara
  • IL-17 inhibitors: Cosentyx, Taltz

Lifestyle Modifications

Besides drug therapy, lifestyle choices can also greatly affect patients with psoriasis and can trigger flare ups of more severe disease. Psoriasis triggers (what causes a flare up of skin plaques) are different for each person. Stress, injury to skin, medications, allergies, diet and weather (extreme cold or heat) all can cause psoriasis symptoms to get worse. It’s also important to remember that lifestyle management is just as important as drug treatments. By following a healthy diet rich in fruits and vegetables, whole grains, and lean meats, as well as omega-3 fatty acids (salmon, soybean oil, and spinach) the chances of maintaining a healthy weight increase greatly. Meditation, massage or yoga may also be helpful to decrease stress. It’s important to know you are not alone and knowing a group of people who share your condition can be effective in helping you cope better with your condition. Private counseling or joining a community or online psoriasis support group may also be helpful.

Helpful skin care tips:

  • Vaccinations, sunburn and scratches can all trigger what is known as a Koebner response, or skin lesions appearing at the site of the trauma. It’s important to protect your skin and wear SPF sunscreen 15 or higher.
  • Another way to protect the skin is to take lukewarm baths or showers and use soap that is made from fats and oil or that contains moisturizing oil.
  • Keep the skin clean and moisturized by applying heavy oil-based moisturizer to skin after bathing to prevent dry skin and reduce scaling.
  • Keep in mind that changes in weather may make skin drier and more susceptible to a psoriasis outbreak.
  • Keep nails groomed to avoid peeling and cracking if nails are affected.
  • Certain medications can worsen psoriasis (such as lithium, antimalarials, quinidine and indomethacin)
  • Environmental allergies can trigger worsening of psoriasis

Overcoming Medication Challenges

It is important for you to know the benefits of your medications. Here at Magellan Rx, we understand your concerns and want to help you with any difficulties you may encounter. For additional information on how to overcome medication challenges, please click here: Overcoming Medication Challenges