What to Do if Topical Treatments Aren’t Enough for Treating Psoriasis

As psoriasis progresses or becomes more severe, though, topical treatments may not be enough to ease your symptoms. If that’s the case, your doctor may prescribe systemic treatments to calm the source of the inflammation that causes psoriasis.

The good news: There are plenty of options available, says Mark Lebwohl, MD, chairman of the dermatology department at the Icahn School of Medicine at Mount Sinai in New York and past chairman of the Psoriasis Task Force of the American Academy of Dermatology.

Which Topical Treatments Are Used for Psoriasis?

Topical psoriasis treatments include anthralin, corticosteroids, coal tar, and salicylic acid. These medications are applied directly to the skin to reduce inflammation and tamp down overactive skin cell production.

Some people also find relief from psoriasis itch and dryness with over-the-counter skin-care products containing zinc, aloe, or capsaicin.

Although many of these options work well initially, over time your symptoms may progress to the point where they’re no longer as effective.

The Main Sign Your Topical Treatments Aren’t Working

One sign topical treatments may not be enough to manage psoriasis symptoms is if you’re seeing plaques on more areas of your body.

Plaques are the dry, raised, scaly skin patches (lesions) caused by psoriasis. They’re often itchy and tender.

Plaques usually appear on your elbows, knees, lower back, and scalp. If you notice them in new areas, such as your hands or feet, or if you’re seeing more of them, even when using a topical regularly, it may be time for a systemic treatment, Dr. Lebwohl says.

He generally recommends systemic treatments for people who have psoriasis on more than 5 to 10 percent of their body. At that point, “It starts to become very impractical to use a topical,” he says.

The other reason Lebwohl recommends systemic treatments is if topicals just aren’t managing your psoriasis symptoms. He says it’s important to give your treatments time to work, but topicals should have a gradual effect about a month after you start taking them.

If you don’t notice a significant difference in your symptoms within three months, the treatment may not work for you.

Why Topicals May No Longer Be Enough

You may also notice that a topical treatment simply doesn’t control your symptoms like it once did. That may be because your case of psoriasis has become more severe or you’ve developed a tolerance to topical therapies, including steroids, which lessens their effectiveness.

While there are many theories about why that happens, “I do think it’s a real phenomenon,” Lebwohl says. “They just stop working.”

Although older topicals tended to be greasy ointments that were often less effective, newer topicals come in easier-to-use foams and lotions that work well for many people, without the mess. These products should make it easier to stick to your treatment plan, Lebwohl notes.

Topical Versus Systemic Treatments

If your doctor determines that topicals aren’t sufficient to manage psoriasis, they may move you to systemic therapy, says Lebwohl.

Unlike topical medications, which are applied directly to the affected area of skin, systemic psoriasis treatments are taken orally or injected and work throughout the body to help control the inflammation that causes psoriasis. They’re typically prescribed if you have moderate to severe psoriasis or your symptoms no longer respond to topical treatments.

Examples of systemic treatments for psoriasis include:

Other Treatment Options

There are other possibilities your doctor may consider, if topicals are no longer working for you.

“UV treatments work, and they’re safe, and many patients want them for that reason,” says Lebwohl. New UV treatment options use a very specific wavelength that treats psoriasis without increasing cancer risk, he adds.

But UV therapy isn’t right for everyone, as it may require repeated treatments to work, although your doctor can prescribe a portable UV therapy device for use at home. “It’s very impractical for many people, because you have to devote a lot of time to it,” says Lebwohl.

How to Talk to Your Doctor About Changing Treatments

It’s also important to fill out the health questionnaire provided by your doctor. These forms contain all of the essential information your doctor needs, such as your medical history and related conditions, to determine the right treatment for you.

In other words, the drug that will help you is individual to you. “Every patient and each drug has unique characteristics that determine the optimal treatment,” Lebwohl says.

If you need to find a dermatologist or are looking for a second opinion about your treatment options, visit the National Psoriasis Foundation’s Patient Navigation Center.

The Takeaway

• While topical treatments are often an effective first-line therapy for psoriasis, they may not work for more severe cases or your body may build up a tolerance to them over time.
• If your topical treatments for psoriasis aren’t helping as much as they used to, you might need to consider systemic options like oral medications or injections.
• Make sure to talk to your doctor about any changes in your symptoms and explore different treatment possibilities together.