Treatment of Chronic Plaque Psoriasis

Guidelines from the American Academy of Dermatology

Smooth and moist without the hint of a blemish!
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While there is no cure for chronic plaque psoriasis, there are a number of treatments available to help you or your loved one manage the disease well.

These treatments include topical (on the skin) medications, light therapy, systemic or whole body medications, and biologic medications.

Deciding which therapy (or combination of therapies) is right for you depends on many factors like:

  • how much of your body is affected by psoriasis
  • which parts of your body are affected by psoriasis
  • your response to prior psoriasis treatments
  • potential side effects of treatments
  • cost of the treatment
  • convenience
  • your preference—you play a very important role in managing your psoriasis

Plaque Psoriais Treatment Guidelines

According to guidelines set forth by the American Academy of Dermatology, topical treatments (on the skin) are the mainstay treatment for mild plaque psoriasis. Topical therapies are also commonly used alongside light therapy, systemic medications, or biologic medications for people with moderate to severe plaque psoriasis.

Light therapy, systemic medications, and biologic medications can also be used in people whose psoriasis does not improve with topical treatments—in other words, the next step if plaques are especially stubborn.

Topical Treatments

Topical Steroids

Topical steroids are effective and very commonly used to treat mild psoriasis.

They are also often used in combination with other therapies for people with more severe psoriasis.

When prescribing a topical steroid, a dermatologist will consider a number of factors like the location of a person's psoriasis plaques and the severity of their psoriasis. For instance, if a person has a psoriasis plaque on his or her face, a weak (less potent) steroid cream like over-the-counter one percent hydrocortisone cream may suffice.

On the other hand, thicker psoriasis plaques, like those often located on a person's elbows, require a stronger (more potent) prescription topical steroid.

Other factors that you and your dermatologist will consider include the expense of the steroid (some are not covered by insurance) and vehicle of the steroid, or the mode in which it's transported into the skin.

For example, plaque psoriasis on the scalp is usually treated with a steroid solution, foam, or shampoo. On the other hand, if larger areas of your body are involved, a steroid ointment or even a steroid spray may be used. 

It's important to know that topical steroids do carry the potential for adverse effects that can harm both the skin (for example, skin thinning) and the body (for example, high blood pressure and blood sugar). This is why topical steroids should only be used under the guidance of a healthcare professional.


Fragrance-free moisturizers—like petroleum jelly, aloe vera gel, or a thick cream—are used in conjunction with other psoriasis therapies (including topical steroids).

They are applied right after bathing to optimize moisture trapping within the skin. The good news about moisturizers is that they are well-tolerated, inexpensive, safe, and can also reduce the itch or burning pain of psoriasis plaques.

Vitamin D Analogs

Experts believe vitamin D analogs treat psoriasis by blocking excess skin cell production in the outermost layer of the skin. 

Vitamin D analogs used to treat plaque psoriasis include calcipotriene (Dovonex), calcitriol (Vectical), and talcalcitol (Curatoderm). They can be used alone or in combination with a topical steroid.

Skin irritation is the most common local adverse effect of these topical medications. The good news is that this usually improves with time. Rarely, an elevation in blood calcium levels may occur. This is more likely to occur in people with underlying kidney disease or in those applying a greater than recommended dose.


Tazarotene (Tazorec) is a topical retinoid and is believed to reduce excess skin cell production and decrease inflammation in plaque psoriasis. The downside of tazarotene is that it can cause skin irritation, and sun sensitivity (increased risk of sunburn).

It is also a pregnancy category X drug (so must be avoided in pregnancy). Research suggests that this topical therapy is best used in combination with topical corticosteroids.

Coal Tar

Tar has been around for more than 100 years in the treatment of psoriasis. That being said, it is not a mainstay therapy, mostly due to the fact that it is messy and has an odor. It can also cause sun sensitivity and irritate the skin.

On the positive side, tar therapies do not require a prescription. Also, like topical steroids, tar is available in a variety of vehicles including shampoos, ointments, lotions, creams, and even a solution or foam vehicle.


Anthralin (ZithranolRrR) used to be a prominent psoriasis therapy but has now lost popularity (like coal tar) due to less messy alternatives. Anthralin also causes skin irritation, another limiting factor. Finally, research suggests it is not as effective as more potent topical steroids or vitamin D analogs.

Light Therapy

It is not a coincidence that people with plaque psoriasis have an improvement in their skin during the summer time. This is because the sun's rays emit ultraviolet radiation, which is believed to slow excess skin growth in the epidermis (the outermost layer of the skin).

Light therapy is a psoriasis treatment in which people expose targeted or whole areas of their skin to ultraviolet light under the guidance of a dermatologist. The good news is that these treatments can be done at home using a prescribed sunlight device.

The downside is that light therapy requires patience and a time commitment. Frequent follow-ups and monitoring is required, and sunburns, blisters, and even skin cancer are potential adverse effects.

There is also a psoriasis therapy called PUVA, although it is not used very much anymore. PUVA involves taking a medication by mouth called psoralen prior to UVA (found in natural sunlight) exposure. Psoralen can also be given topically in the form of a paint or bath for persistent psoriasis plaques.

Similar to the traditional light therapy, PUVA  increases a person's risk of skin cancer, cataracts (eyes must be protected with goggles for several hours after treatment), and premature aging of the skin.

Finally, a newer and exciting light-based treatment is excimer laser, which targets specific psoriasis plaques. The benefit of laser is that it focuses on a small area of the body, so there are less light-related risks involved like sunburn and skin cancer.

Traditional Systemic and Biologic Treatments

For people with chronic plaque psoriasis that is moderate to severe and/or particularily disabling (due to physical or psychological consequences), a dermatologist will consider one of many traditional systemic or biologic psoriasis medications.

Like topical therapies, there are many factors that go into determining which traditional systemic or biologic medication is best. Some of these factors include cost (biologic agents tend to be more expensive than systemic medications) and the potential for adverse effects.

Of course, any medication requires a thoughtful discussion with a person's dermatologist.

Traditional Systemic Treatments


Methotrexate has been around for a long time (over 50 years) and is believed to improve psoriasis by suppressing a type of immune cell called the T-cell. Research suggests that methotrexate may not be as effective as the newer biologic agents in treating psoriasis.

There are a number of potential adverse effects associated with methotrexate. For instance, minor ones include nausea, loss of appetite, stomach upset, and fatigue. Taking a folic acid supplement, taking methotrexate with food, or as an injection (in the muscle or fat tissue, as opposed to by mouth) can help minimize these discomforts.

There are also a number of serious adverse effects associated with methotrexate including liver toxicity, lung toxicity, and bone marrow suppression, which causes a low number of blood-forming, clot-forming, and infection-fighting cells. Periodic blood tests and possibly a liver biopsy (depending on the dose of methotrexate a person has undergone over time) are required during therapy. 


Acitretin is a systemic retinoid (meaning derived from vitamin A) and is FDA-approved for adults with severe plaque psoriasis. How well acitretin works depends on the dose. That being said, higher doses are often not well-tolerated. The good news though is that when combined with UV light therapy, people tend to respond better on a lower dose.

It's important to note that acitretin is a pregnancy category X medication so is absolutely contraindicated during pregnancy. Common side effects include cheilitis, hair loss, and drying of the eyes, nose, and mouth. While taking acretin, your doctor will also monitor your liver function tests and your cholesterol levels.


Cyclosporine is FDA approved to treat plaque psoriasis that is extensive or disabling and has not responded to at least one other systemic therapy. Cyclosporine suppresses the immune system and works quickly and effectively, although it does require blood pressure and kidney monitoring—this usually limits its long-term use.

Biologic Treatments

Biologic agents are made from human or animal proteins and are used to treat adults with moderate to severe plaque psoriasis. These newer medications work by blocking a specific part of the immune system, as opposed to systemic medications which act on a person's whole immune system.

The specific proteins that biologic agents block include tumor necrosis factor (TNF) and interleukin 12, 23, and 17a. These proteins are increased in people with psoriasis. So by blocking them, psoriatic-related inflammation in the body is reduced.

Inhibitors of tumor necrosis factor (TNF) used to treat moderate to severe plaque psoriasis include the biologic agents: adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade).

Ustekinumab (Stelara), which block the proteins interleukin 12 and interleukin 23, and secukinumab (Cosentyx) and ixekizumab (Taltz), which block interleukin 17-A, are also used in treating moderate to severe plaque psoriasis in adults. 

Biologic agents are given as either an injection or through the vein. They do carry risks and require careful monitoring. In fact, before starting a biologic, a person's dermatologist will order a number of blood tests as a baseline for monitoring potential adverse side effects. These blood tests commonly include a liver function test, a blood cell count, a hepatitis panel, and tuberculosis testing (the biologic agents that suppress TNF can lead to tuberculosis reactivation).

While on a biologic, a person will have these blood tests repeated periodically and will also be carefully monitored for signs and symptoms of infection or cancer.

Newer Treatment


Apremilast (Otezla) is a newer psoriatic medication that works by blocking an enzyme called phosphodiesterase 4, which regulates inflammation within cells. It's taken by mouth and used to treat moderate to severe plaque psoriasis. Research suggests it's well-tolerated, although it may cause diarrhea, nausea, and/or headaches when first started. Some people also experience weight loss or symptoms of depression.

A Word From Verywell

While psoriasis is a very complex disease, and this includes how it's treated, continue your patience and resiliency. In the end, treating it will improve your quality of life and may even lower your chances of developing other health problems that have been linked to psoriasis.

In addition, remember treating psoriasis requires a personalized approach, so what works for you may not work for someone else. Be assured that there is a way to live well with psoriasis, even though it is not yet curable.


American Academy of Dermatology Work Group et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions. J Am Acad Dermatol. 2011 Jul;65(1):137-74.

Chiricozzi A, Caposiena D, Garofalo V, Cannizzaro MV, Chimenti S, Saraceno R. A new therapeutic for the treatment of moderate-to-severe plaque psoriasis: apreilast. Expert Rev Clin Immunol. 2016;12(3):237-49.

Menter A et al. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents. J Am Acad Dermatol. 2009 Sep;61(3):451-85.

National Psoriasis Foundation. Light Therapy.

National Psoriasis Foundation. Moderate to Severe Psoriasis and Psoriatic Arthritis: Biologic Drugs.

Saurat JH et al. Efficacy and safety results from the randomized controlled comparative study of adalimumab vs. methotrexate vs. placebo in patients with psoriasis (CHAMPION). Br J Dermatol. 2008 Mar;158(3):558-66.

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