So many psoriasis treatment options: which one(s) for you?

Advances in treating plaque psoriasis and psoriatic arthritis are transforming lives, and this has given us a wonderful problem: How to choose among many promising treatment options?

We believe that this decision should be made by you in close consultation with your dermatologist or rheumatologist. Our goal in this discussion of many of the factors to be considered, is to send you into that appointment with the information you need to communicate your personal priorities effectively to your physician.

Our goal is NOT to overwhelm you with the many considerations that could go into making this determination, though that could happen, as you will see below! Keep in mind that even if a treatment option fails you, there are many other options likely to work. Fortunately, for most of us, there is more than one correct answer on this test.

As you review the following questions that should inform your selection of a psoriasis or psoriatic arthritis treatment, note that we do not discuss specific treatment names on this page. For details on specific treatments by brand and generic name, see the next page in our Treatment section: Psoriasis and psoriatic arthritis treatment options.

We’ll start with some of the core issues that must be addressed in selecting a treatment.

Do you have moderate to severe plaque psoriasis?

If your psoriasis is mild, head over to treatments for mild psoriasis, as you are lucky it is mild, and your decision is easier. If you also have, or have had, inverse, guttate, pustular, or erythrodermic psoriasis, that too could impact your treatment choice.

Have you been diagnosed with psoriatic arthritis?

Do you have arthritic symptoms like a sore back, joint pain, swollen digits, morning stiffness that improves once you get moving, etc.? If so, tell your doctor. It could be psoriatic arthritis. While most treatments benefit both psoriasis and psoriatic arthritis, some treatments are considered more effective in certain cases than others, and there are a few that do not have FDA approval (not yet, anyway) for one or the other condition.

Are you female?

Selecting an appropriate treatment option can be trickier for pregnant women, women of child-bearing potential, and nursing mothers.

What is your age?

There are a few U.S. Food and Drug Administration (FDA) approved treatments for minors with moderate to severe psoriasis or psoriatic arthritis, and others only approved for adults can be prescribed for children “off label” by doctors, based on what the medical community has learned and the needs of a particular child.

On the other side of the age continuum, there is less experience treating elderly patients with these newer therapies, an issue that you and your physician will want to consider if that applies to you.

Do you have other significant health issues?

Your cancer history, the health of your heart, kidneys, and liver, your cholesterol levels; these are some of the issues that could impact your treatment selection.

Do you or a close relative have inflammatory bowel disease (Crohn’s disease or ulcerative colitis)? Some psoriasis treatments are FDA-approved also for these diseases, while at the same time, others of these treatments can occasionally trigger new or make worse existing IBD.

Do you have depression or anxiety, or other mood disorders (whether diagnosed or merely suspected)? Some of these treatments are being shown to improve patient-rated emotional state and quality of life, while others carry warnings that they can trigger depression or suicidal thoughts, or make existing depression worse. Even if not diagnosed, you should discuss any possible mood issues with your physician as part of your psoriasis treatment process.

How will you pay for treatment?

Many of these treatments are very expensive. Do you have insurance (private, Medicare, Medicaid, VA/TRICARE)? Does your insurer put any roadblocks in the way of your obtaining the treatment your physician has prescribed? (This is sometimes called “step therapy” or “fail-first”?) Have you looked into programs available to help commercially-insured people to reduce out of pocket costs, or programs to help uninsured individuals access these treatments? Doctors are very aware of the need for patients to be mindful of costs and they will work with you to find the best treatment that works within your cost constraints. The key: do not be shy about raising cost issues.

What is your level of concern about side effects, or your risk tolerance?

This can be hard to quantify, but the various treatments have different potential side effects, different rates of serious and non-serious side effects, have been on the market for different numbers of years, and have been used by different numbers of people. Some people care a great deal about these issues, and others are more focused on effectiveness. (All of these treatments have been FDA-approved, of course, meaning for certain people the expected benefits of the treatment outweigh the expected risks.)

For example, one pill helpful in psoriasis and psoriatic arthritis has been used since the 1950’s. The first “biologic” psoriasis treatments were US-approved more than 20 years ago. The most recent psoriasis treatment approval came in 2019. Similarly, some treatments have been used by more than one million people across various diseases; others have been used by just thousands of people. Some people don’t mind being early adopters of a new treatment, while other people prefer to let others go first, and let some time pass, before they are willing to try it. This is a personal preference that you can share with your physician as you select a treatment together.

How do you define effectiveness?

Do you have specific effectiveness measures that are most important to you? This could be how quickly a treatment provides substantial relief, how thoroughly it ultimately clears the skin or reduces / eliminates joint pain, and/or how many years the improvement has been shown it can be maintained (since psoriasis and psoriatic arthritis are lifelong diseases). Those with psoriatic arthritis might also insist on one of the treatments that have been clinically shown to stop progression of irreversible joint damage.

Do you have psoriasis in certain body areas that is particularly distressing to you?

Psoriasis treatments are increasingly being studied in specific parts of the body, giving health care practitioners evidence-based help in selecting a particular treatment for a particular patient. For example, the effectiveness of certain treatments on psoriasis of the scalp, hands, feet, nails, and/or genital area have been specifically documented in clinical studies. Doctors also gather anecdotal evidence on these and related issues. If your number one goal of treatment is to clear a particular area or areas of your body, be sure to tell your doctor.

Is your body weight on the larger side and/or are you obese? Or are you on the smaller side?

Some treatments are dosed differently for larger people, so if you are a larger person, you might want to try one of those options as there is evidence that it can improve treatment response for those individuals.

Similarly, some treatments have smaller dosing available, which might be enough to work for a smaller person, and less medicine may mean less chance of side effects.

Do you have a strong preference for how a treatment is administered?

The primary treatments for moderate to severe plaque psoriasis and psoriatic arthritis are either pills, brief injections under the skin (either done by you, a loved one, or by a health care provider in a medical setting), standing in front of special ultraviolet lights at home or in a medical setting, or as treatments given to you intravenously while you sit at a medical infusion center. We would note that people who self-inject under the skin generally find it not to be a problem after a couple of tries; and that patients often read, check their email, or watch TV while getting their infusions.

How important are convenience factors in your treatment choice?

For example, a fairly standard course of narrowband UV light treatments for psoriasis could require three visits per week to a medical office for six to 12 weeks, while there are biologics that, once started, require as few as four injections per year. Other patients take pills one day a week for their psoriasis and psoriatic arthritis, while still others take a different treatment pill twice daily.

Other convenience factors could include that certain treatments are not compatible with consumption of alcohol; and that certain frequent travelers might find their schedules not compatible with certain treatment regimens.

 

Now that you know some of the factors to consider in selecting a treatment, let’s move on to the specific treatments currently available in the United States: Psoriasis and psoriatic arthritis treatment options.

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