Psoriasis is a chronic condition and its treatment varies depending on its severity. A combination of topical agents, phototherapy, and systemic medications are used when psoriasis is severe.
Psoriasis is a chronic, immune-mediated condition characterized by patches of raised, scaly, inflamed skin that can appear anywhere on the body.
Many types of psoriasis exist, but plague psoriasis is the most common and features well-defined areas of red or discolored skin with silver-white scales, referred to as “plaques.”
Most types of psoriasis go through
- Progressive stage: worsening or active disease
- Stationary stage: stable, unchanging disease
- Regressive stage: disease improvement or remission
During each phase, your dermatologist scores psoriasis severity using several clinical scales that evaluate how much of your body is affected, the size, location, and number of psoriasis patches, and the characteristics of the affected areas.
A final severity score is determined by combining your affected body surface area (BSA) with your scores from the Psoriasis Area and Severity Index (PASI) and Investigator’s Global Assessment (IGA).
Psoriasis is considered severe
- BSA is equal to or greater than 10%
- PASI is equal to or greater than 10
- IGA is a 3 or higher (up to 5)
Severe psoriasis is
Topical medications
Topical medications are considered a “stage 1” treatment. They’re used primarily to manage mild psoriasis.
Your dermatologist may still prescribe topical agents in combination with other therapies if psoriasis is severe. These products can help soften scale, reduce inflammation, and ease symptoms like itching.
Common topical agents include:
- corticosteroids
- vitamin D
- topical calcineurin inhibitors
- salicylic acid
- tazarotene
- roflumilast
- tapinarof
- coal tar
- anthralin
Systemic medications
Systemic medications are those that work throughout your entire body. They’re reserved for moderate to severe cases of psoriasis, psoriasis with joint involvement (psoriatic arthritis), and psoriasis that’s resistant to traditional therapies.
First-line options
First-line systemic therapies target immune responses that contribute to inflammation in psoriasis. By targeting inflammation, these medications can help reduce lesions and improve discoloration, swelling, scaling, and pain.
Some also work to slow the progression of joint damage from psoriatic arthritis.
Common systemic medications include:
- cyclosporine
- methotrexate
- apremilast
- upadacitinib
- acitretin
- deucravacitinib
- tofacitinib
Additionally, intralesional injections of triamcinolone (a corticosteroid) are often
Phototherapy
Phototherapy comprises “stage 2” of psoriasis treatment. Your dermatologist will recommend this therapy for psoriasis that can’t be managed using topicals alone, which includes cases of severe psoriasis.
Phototherapy, also known as light therapy, involves ultraviolet light exposure under medical supervision to slow the excessive growth of psoriasis skin cells.
Your dermatologist can administer phototherapy using special devices, like an excimer laser, in combination with creams and medications that increase your skin’s sensitivity to ultraviolet light.
‘Stage 3’ biologics and biosimilars
Psoriasis, in its most severe presentation, is a candidate for biologic and biosimilar medications.
These medications represent “stage 3” treatments for situations where topical, phototherapy, and other systemic medications aren’t able to manage symptoms successfully.
Biologics are medications produced using living cells. They contain components of living organisms, like proteins that help them work more efficiently in the body.
Biosimilars are produced in a similar manner and are medications that are “highly similar” to an already existing biologic when it comes to safety, quality, and efficacy.
Both biologics and biosimilars work to target very specific immune pathways in psoriasis to help control symptoms and disease progression. They’re usually administered by your dermatologist through an injection or an infusion into your vein (IV).
Examples of biologics and their biosimilars approved for the treatment of severe psoriasis include:
- Biologic: Humira; Biosimilar: Abrilada
- Biologic: Enbrel; Biosimilar: Erelzi
- Biologic: Remicade; Biosimilar: Avsola
- Biologic: Stelara; Biosimilar: Wezlana
Lifestyle modifications are the everyday healthy living changes you can make to support your well-being and the success of medical therapies for psoriasis.
Lifestyle modifications are a part of every comprehensive psoriasis treatment plan and include:
- eating a balanced, anti-inflammatory diet
- exercising regularly
- maintaining an optimal weight
- developing stress management and coping strategies
- learning relaxation techniques
- getting plenty of quality sleep
- staying hydrated
- eliminating substance use
- smoking cessation
It can take time for psoriasis treatments to reach peak effectiveness. Some medications, like Humira, can take several weeks before you notice improvements in your symptoms.
Your dermatologist will provide an estimated timeline for improvement based on the medications selected for your individualized treatment plan.
Signs your treatment is not working include:
- No symptom improvement within the expected time frame.
- Psoriasis lesions spread, appear in new places, or worsen in appearance or level of discomfort.
- Symptoms stop improving sooner than expected.
- The treatment goals set by you and your dermatologist aren’t being reached.
When you’re on combination therapy for severe psoriasis, it can be difficult to know when it might be time to try something new — and what therapy should be adjusted. Keeping in regular communication with your dermatologist can help you explore treatment changes as soon as they might be needed.
Topics to discuss when you visit your dermatologist include:
- changes you’ve noticed in your symptoms
- new concerns you might have about symptoms, side effects, or quality of life
- lingering symptoms or concerns that never resolved fully with treatment
Other questions that can help you and your dermatologist discuss treatment changes include:
- Are my symptoms improving at the expected rate?
- Are the treatments I’m on still considered the most effective for my goals?
- Have any new therapies been approved for the treatment of severe psoriasis?
- Are there any medication dosing adjustments that might make a positive difference?
- Should I consider a clinical trial? Why or why not?
It can be helpful to come to your appointment prepared to discuss medications you’ve researched and are interested in considering. Explain to your dermatologist why you want to try a new therapy and why the ones you’ve researched are appealing to you.
Your dermatologist is skilled in diagnosing and treating psoriasis, but they don’t have detailed insight into how it affects your life on a personal level. Being honest about your concerns and challenges in daily life can help your doctor find the right therapy for you.
Psoriasis is a chronic immune-mediated condition that causes patches of inflamed skin. It can vary in type, symptoms, and severity and may require various treatment approaches.
The most severe presentations of psoriasis often require “stage 3” treatment options, such as biologic and biosimilar medications. These products target specific molecular pathways in the immune processes underlying psoriasis.
When symptoms continue to worsen or aren’t improving, your dermatologist can discuss alternative therapies and medications based on your individual needs.