Psoriasis Medication Side Effects

Major advancements in psoriasis treatments in the past two decades have given people living with the autoimmune condition a wide range of options for controlling symptoms. There are more than a dozen systemic treatments alone, which include some of the newer medications like Janus kinase (JAK) inhibitors.

But psoriasis treatments include many “old-school” medications as well, mainstays of therapy that have been around for decades. The one thing that all these options have in common? Side effects, which can range from mild to bothersome, and in some cases, a risk of serious adverse events.

Keep reading to learn what you need to know about the most common side effects from the most used psoriasis treatments.

Topical corticosteroids are among the most commonly prescribed treatments for psoriasis because they reduce inflammation, redness, and irritation, says Susan Massick, MD, an associate professor of dermatology at the Ohio State University in Columbus.

But if they’re used too frequently or for too long, they can cause skin atrophy, or thinning of the skin, says Dr. Massick.

• Noticeable blood vessels (telangiectases)
• Hypopigmentation (light-colored skin)
• Easier bruising
• Delayed wound healing
• Acne breakouts
• Stretch marks (striae)

“This can happen with low-potency topical steroids when used for prolonged periods of time, or with higher-potency topical steroids when applied in more sensitive areas, such as the face, armpits, groin, or genitals, or if used for prolonged periods of time,” she says.

Massick recommends working with your medical provider to limit the length of treatment to short-term or intermittent use and avoid prolonged or continuous treatment times.

“Your dermatologist will tailor what type of topical steroid depending on how severe your disease is and what areas need to be treated, with lower-potency topical steroids reserved for the delicate areas of the face, armpits, breasts, and genital areas, and with higher-potency topical steroids more appropriately reserved for places like your arms, legs, hands, feet, and trunk — and not to be used on the face,” says Massick.

Medications like calcipotriene (also called calcipotriol), a synthetic form of vitamin D, are often paired with topical steroids to treat psoriasis. They’re generally well tolerated and don’t directly cause sun sensitivity, though using sun protection and wearing protective clothing and a hat are precautions worth taking, according to Massick.

In psoriasis, keratinocytes (the type of cell that makes up most of the epidermis, the outermost layers of the skin) build up faster than normal, leading to the thick patches on the skin known as plaques.

Topical retinoids such as tazarotene (Fabior, Tazorac, Avage) treat psoriasis by reducing the overproduction of keratinocytes; promoting normal differentiation, or maturation, of keratinocytes; and exerting anti-inflammatory effects.

But patients do notice signs of skin sensitivity like redness, dryness, peeling, and irritation, especially when first starting treatment, says Massick.

“I recommend starting low and slow: Start with using the product two to three times a week to get acclimated to any potential irritation, and then increase the frequency as long as you’re not experiencing skin irritation,” she says.

“While coal tar can reduce inflammation by slowing the rapid skin cell turnover — the hallmark of plaque psoriasis — it also has a very pungent smell and can stain clothing, bedding, and towels,” she says.

Coal tar can also cause skin irritation in some people, especially when used in higher concentrations or on sensitive skin, says Massick.

For people who find that coal tar is a good way to manage psoriasis, they can limit skin irritation by using a lower concentration or using it on alternating days.

Psoriasis is an autoimmune disease; the immune system is triggered and activated as if there were harmful invaders attacking the body. Sometimes topical therapies aren’t enough to control inflammation, and systemic therapies — drugs that address the root cause — are needed.

“Biologic medications target specific components of the immune system’s response and inflammatory cascade that trigger the psoriasis inflammatory pathway. These medications can block specific targets, such as IL-17, IL-23, and TNF alpha, all of which play key roles in psoriasis,” explains Massick.

Because these medications work by suppressing part of your immune system, they are considered immunosuppressants, she says.

Any suppression of your immune system can increase your risk of infection in general.

“This includes infections such as the typical upper respiratory viral and bacterial infections, such as influenza (flu) and COVID-19, and, in rare cases, more serious infections like tuberculosis,” says Massick.

“Prior to starting therapy with any of the biologics, your doctor will screen you for chronic infections, including HIV, tuberculosis exposure, and hepatitis B and C, and will continue to monitor you during your treatment course,” she says.

JAK inhibitors are oral drugs that can help with chronic inflammatory conditions, including psoriasis.

“These are the new kids on the block, one of the newer classes of medications that are effective in chronic inflammatory conditions, such as eczema and psoriasis. JAK inhibitors work by targeting specific inflammatory signaling pathways within cells that lead to inflammation,” says Massick.

While JAK inhibitors have been shown to be effective, they do carry potential serious risk of internal, or systemic, side effects, including increased risk of infection, bone marrow changes with low white counts, blood clots, heart-related events, and increased risk of cancer, she says. Not every patient will experience these side effects; some risks can depend on an individual's medical history and risk factors, says Massick.

“A blood clot, such as a deep venous thrombosis (DVT), can cause swelling or pain where the clot forms, most commonly in the lower legs, developing as localized calf redness, swelling, and pain. If the clot travels to the lungs, this can cause a pulmonary embolism, causing shortness of breath and much more severe complications,” she says. A pulmonary embolism is a medical emergency.

Because of this risk, prescribing JAK inhibitors requires careful consideration to ensure that the severity of psoriasis outweighs the potential risk of these more serious side effects, says Massick.

“JAK inhibitors are associated with increased risk of non-melanoma skin cancers particularly in conjunction with other risk factors for skin cancer like age, fair skin, and history of skin cancers and sunburns,” says Massick.

“In terms of counseling, I do choose very carefully who I will offer these treatment options to and have frank discussions regarding potential side effects and long-term effects of these newer systemic therapies. While efficacious in terms of disease control, they are not without their risks,” says Massick.

• Psoriasis treatments can control symptoms, but each treatment has potential side effects to weigh against benefits.
• Topicals like corticosteroids, vitamin D analogues, retinoids, and coal tar mainly cause skin issues such as irritation, thinning, or staining, which can often be managed by adjusting the dosage.
• Biologics and JAK inhibitors target immune pathways for stronger control but can raise the risk of serious infections; JAK inhibitors may also increase blood clot and cancer risk in certain people.
• Work with your dermatologist to choose, monitor, and adjust your psoriasis treatments to balance effective symptom control with safety.