Types of psoriasis medication: oral, topical, biologics

If you have psoriasis, you probably know that sometimes this chronic skin condition can be uncomfortable and that it can be challenging to control the symptoms it causes. Fortunately, with the right treatments, you can find some relief. A complete treatment plan for psoriasis can involve multiple strategies, including skin care routines, trigger avoidance, light therapy, and medications. In some cases, you may need more than one type of psoriasis medication to treat or prevent it. Needless to say: it’s a lot of information to process.

Read on for an overview of the types of psoriasis medications to gain a better understanding of the treatments that may be available to you.

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Psoriasis affects more than 7.5 million people aged 20 years and older in the United States (Armstrong, 2021). It’s a chronic condition that causes rapid overproduction of skin cells and skin inflammation. Its cause isn’t known, but it is most likely immune-mediated (Nair, 2021). 

With plaque psoriasis, the most common type of psoriasis, skin cells pile up on the skin’s surface, forming raised, scaly areas called plaques. Plaques most often appear on the scalp, elbows, and knees but can occur anywhere on the body, including the hands, nails, and feet. Plaques may appear red, purple, silvery-white, or grayish-brown, depending on your skin tone. These areas can be itchy or painful (Badri, 2021; Menter, 2019).

There isn’t a cure for psoriasis, and the symptoms come and go over time, with symptoms getting worse during “flares” and better during times known as “remission.” Certain factors like stress, infections, and scratching the skin can trigger flares. Some medications you only use during a flare, and others you can use all of the time (Nair, 2021). 

Most treatment plans for psoriasis include one or more prescription medications. The two main categories of psoriasis medications are topical (drugs that you apply to the skin, like creams and ointments) and systemic (oral or injected medicines that work throughout your body). 

You apply a topical psoriasis medication directly onto scalp or skin lesions. Examples are medicated creams, ointments, gels, shampoos, foams, and sprays. Most topical medications work within your skin’s layers and don’t absorb into your bloodstream to a great extent. In some cases, you can use topicals alone, especially for mild psoriasis, or you can use them along with systemic therapy. Of these topical medications, healthcare providers most commonly prescribe corticosteroids (Elston, 2020; Feldman, 2021).

Topical corticosteroids

Topical corticosteroids work within the skin’s layers to suppress inflammation and control psoriasis flares. Usually, unless your healthcare provider instructs you otherwise, you apply them directly to the affected areas of your skin or scalp. Some common examples of topical corticosteroids and their brand names include (Elmets, 2020; FDA-a, n.d.):

• Betamethasone dipropionate (Diprolene)

• Clobetasol propionate (Temovate)

• Diflorasone diacetate (ApexiCon E, Psorcon)

• Fluocinonide (Lidex, Vanos)

• Halobetasol propionate (Ultravate)

You should only use corticosteroids in moderation. Overdoing it with these medications, especially over large areas of your skin, can lead to side effects like skin atrophy. With skin atrophy, your skin thins and becomes more transparent. Your skin may also become more vulnerable to infection, irritation, or discoloration (Elmets, 2020; Elston, 2020).

To help minimize these side effects, your healthcare provider may suggest a regimen that alternates between corticosteroids and other topical treatments. Other common non-steroid topical psoriasis medications include tazarotene and calcipotriene (Elmets, 2020).

Retinoids (Tazarotene)

Tazarotene belongs to a class of drugs called retinoids. It is available in several brand-name prescription products like Tazorac, Avage, Fabior, and Arazlo. Healthcare providers usually prescribe it for mild-to-moderate psoriasis and often in combination with corticosteroids. Tazarotene may be a particularly effective psoriasis medication for nail psoriasis and palmoplantar psoriasis (a type of psoriasis that affects the palms of the hands and soles of the feet) (Elmets, 2020; FDA-a, n.d.).

Tazarotene may cause side effects like redness, burning, and itching, and healthcare providers do not recommend it during pregnancy (Elmets, 2020).

Vitamin D (Calcipotriene)

Calcipotriene is a form of vitamin D. Brand-name versions of this medication include Calcitrene, Dovonex, and Sorilux. Healthcare providers prescribe it long-term to treat mild-to-moderate psoriasis, including psoriasis of the scalp and face. Some healthcare providers prescribe it as part of a regimen with corticosteroids (Elmets, 2020; Elston, 2020).

Calcipotriene’s common side effects include burning, itching, fluid buildup, peeling, dryness, and redness, but these side effects tend to go away as you continue treatment. Rarely, this medication can cause serious side effects like high blood levels of calcium, mainly if you use it on large areas of your skin’s surface or if you have kidney problems (Elmets, 2020).

Combinations and other topicals

Some topical psoriasis medications contain combinations of two different active ingredients. For example, Enstilar and Taclonex contain calcipotriene and a corticosteroid, betamethasone (Elmets, 2020; FDA-a, n.d.). 

Other topicals to treat psoriasis contain different active ingredients like coal tar or salicylic acid, some of which are available over-the-counter. Your healthcare provider can tell you more about the pros and cons of these psoriasis medication options (Elmets, 2020; Miceli, 2021).

Systemic (“throughout-the-body”) medications are either oral drugs like tablets or capsules that you swallow or injectable drugs that are given as injections under the skin or as infusions into a vein. The systemic treatment category also includes biologic drugs (biologics are drugs made from living cells using biotechnology) (Mikhaylov, 2019; Feldman, 2021).

These medications work throughout the body, not just in your skin’s layers. Systemic psoriasis medications are ongoing, long-term treatments. They are meant to increase the amount of time you spend in remission. But, when flares occur, you may still need to use topicals like corticosteroids, along with systemic treatments, according to your healthcare provider’s instructions (Menter, 2019; Mikhaylov, 2019).

If your healthcare provider feels that systemic psoriasis treatment is right for you, they’ll discuss the risks and benefits with you and consider your overall health when choosing a specific treatment. They may prescribe a systemic psoriasis medication that may have beneficial effects for other chronic health conditions that you may have, such as heart disease, psoriatic arthritis, ulcerative colitis, or Crohn’s disease. On the other hand, they’ll try to avoid medications that could worsen your other medical conditions (Mikhaylov, 2019; Hu, 2017).

Biologics (also known as biological products) are different from traditional medications because they are large, complex molecules made from living cells using biotechnology. In contrast, traditional medications (e.g., aspirin tablets) are small molecules made from chemicals (FDA-b, n.d.).

Biologic treatments work well for moderate to severe plaque psoriasis, and most people tolerate them well. They also offer the advantage of infrequent dosing options. Some biologics like Enbrel only require a dose once or twice a week, while others like Stelara require one dose every three months (Feldman, 2021; Mikhaylov, 2019).

Biologic drugs carry several risks, such as reactivating past viral infections like tuberculosis or hepatitis B or increasing the chance of skin cancer. If your healthcare provider prescribes a biologic drug for you, expect to get bloodwork done regularly during treatment to monitor for these risks and other side effects (Menter, 2019). 

Another downside of biologic drugs is their high cost, which can be thousands of dollars per month. So, healthcare providers usually reserve biologics for people with cases of more severe or tough-to-treat forms of psoriasis (i.e., when the disease affects the skin of the palms and soles), for which other medication types failed to be effective (Feldman, 2021; Miceli, 2021). 

Unfortunately, biologic drugs do not come in pill form. They are only available as injections or infusions, and your healthcare provider will typically administer them at their office or another medical facility. In some cases, you can self-inject biologic drugs at home after a healthcare professional teaches you how to properly prepare and administer your dose (Menter, 2019).

Here is a look at a few popular biologic psoriasis medications and some key information about them.

TNF inhibitors

Medical professionals prescribe TNF inhibitors to treat moderate to severe plaque psoriasis. They can be highly effective but carry several major risks, including serious infections. Common TNF inhibitors include (Menter, 2019; Feldman, 2021):

• Adalimumab (brand name: Humira) 

• Etanercept (brand name: Enbrel) 

• Infliximab (brand name: Remicade)

Monoclonal antibodies

Monoclonal antibody drugs are the newest type of psoriasis medications. They work to decrease inflammation in the body by modifying how your immune system responds to specific targets. These drugs can treat several types and subtypes of severe psoriasis, including plaque, pustular psoriasis, erythrodermic psoriasis, inverse psoriasis, and guttate psoriasis. In addition to psoriasis, drug manufacturers develop monoclonal antibody drugs to treat cancers and other conditions that involve the immune system, like psoriatic arthritis and rheumatoid arthritis (Menter, 2019; Mikhaylov, 2019).

Common monoclonal antibodies for psoriasis include:

• Ixekizumab (brand name: Taltz)

• Risankizumab (brand name: Skyrizi)

• Secukinumab (brand name: Cosentyx)

• Ustekinumab (brand name: Stelara)

Several oral (by-mouth) drugs are also available for psoriasis. Oral medications tend to be less expensive than biologics, and most require once- or twice-daily dosing. Serious side effects can happen with oral psoriasis medications, so healthcare providers only use some of these treatments for severe cases when other treatments aren’t an option (Chat, 2021; Feldman, 2020).

Common oral psoriasis medications include acitretin, apremilast, cyclosporine, and methotrexate. 

Acitretin

Healthcare providers prescribe acitretin (brand name: Soriatane) to treat severe plaque or pustular psoriasis. When you first start taking acitretin, your psoriasis may get worse before it gets better. It typically takes two to three months of acitretin treatment before you notice improvement (Stiefel, 2017; Zito, 2021). 

Acitretin warnings: Acitretin carries a strong warning from the FDA due to the risk of severe congenital disabilities. Strict rules are required for taking this medication, like pregnancy testing and using two forms of birth control while taking acitretin and at least three years after your last dose (Stiefel, 2017).

Apremilast

Apremilast (brand name: Otezla) is a fairly new oral psoriasis medication, receiving its FDA approval in 2014. Medical providers prescribe it to treat moderate-to-severe plaque psoriasis, among other uses. The usual dosage is one tablet twice daily. It commonly causes digestive side effects like diarrhea and nausea and rarely may cause severe depression or suicidal thoughts (Amgen, 2020).

Cyclosporine

Cyclosporine (brand name: Neoral) is an immunosuppressant medication that you take twice a day. Among other uses, the FDA approves it for treating severe plaque psoriasis. The drug carries several strong FDA warnings, including increased risks of infections, skin cancer, high blood pressure, and kidney damage (Novartis, 2015).

Methotrexate

Methotrexate (brand name: Trexall) is an immunosuppressant drug that people use as a psoriasis medication to treat severe plaque psoriasis and nail psoriasis, among other autoimmune conditions. Healthcare providers usually prescribe it as a once-weekly treatment (Mylan, 2019).

Methotrexate warnings: Methotrexate treatment comes with several strong warnings from the FDA. These include the risk for congenital disabilities and pregnancy loss (miscarriage), serious infections, and liver damage. Because of these risks, treatment with methotrexate requires birth control and blood tests to monitor for side effects (Mylan, 2019).

There is no single “best” treatment option for psoriasis. If you’re not satisfied with your current treatment or psoriasis medication, it’s a good idea to have a conversation with your healthcare provider. Trial-and-error and dosage adjustments may be necessary to find a treatment plan that works for you. Psoriasis is uncomfortable, but with the right treatment plan, you can find some relief. 

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Current version

October 18, 2021

Written by

Patricia Weiser, PharmD

Fact checked by

Felix Gussone, MD

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About the medical reviewer

Felix Gussone, MD, Ro

Felix Gussone is a physician, health journalist and a Manager, Medical Content & Education at Ro.