Treatment of psoriasis

What it is

On deeper skin it tends to look violaceous or gray-brown rather than salmon-pink, the scale is thicker, and it leaves prominent pale or dark patches after it clears that patients often mistake for a new problem. The visit confirms the diagnosis, records how much skin and which sites are involved, asks about joints, and builds a treatment plan for a condition that relapses.

What this page covers

• Plaque psoriasis: diagnosis, extent, effect on daily life, and a topical plan of vitamin D analogue and corticosteroid combinations with emollients
• Scalp psoriasis, with the vehicle — oil, foam, gel or shampoo — chosen for hair texture and covering habits so the regimen is actually used
• Facial, flexural and genital (inverse) psoriasis, where potency is limited and steroid-sparing options carry most of the plan
• Nail psoriasis: pitting, oil-drop change, onycholysis and thickening, with fungal infection excluded by sampling first
• Psoriatic arthritis screening at every visit
• Phototherapy, systemic therapy and biologic referral, with tuberculosis and hepatitis screening and ongoing monitoring
• Recognition of the severe flare that follows abrupt withdrawal of oral or high-dose systemic steroids started elsewhere
• Metabolic risk review at diagnosis
• Separating scale-related shedding from a scarring alopecia before reassuring a patient about hair loss

Who it suits

• Someone with thick scaly patches that quiet down and come back, who wants the diagnosis confirmed and a plan that is followed up, rather than one cream handed over once
• Someone whose scalp has been treated as "dandruff" for years without meaningful improvement
• Someone whose nails have changed — pitting, lifting, thickening — and who was told fungus without a sample ever being taken
• Someone starting to notice something in the joints: morning stiffness, a whole finger swollen, pain in the heel
• Not you if you are looking for a course that ends. Psoriasis relapses; treatment aims at control and at long quiet periods. And if the disease is extensive or the joints are involved, the honest answer is a monitored systemic or biologic pathway shared with rheumatology — we say so and refer, rather than running it inside a cosmetic appointment

When we advise delaying or not treating

• Cortisone taken to settle the whole flare quickly — a course of tablets, or an injection into a muscle. We decline systemic steroids in psoriasis. The skin quiets for a short time, the disease then returns less stable than it was, and stopping it abruptly can set off a severe flare — see the box above. This is about cortisone given for the whole body; an injection placed into a single stubborn plaque or nail is a different decision, made at the examination
• Any elective cosmetic procedure on or beside an active plaque: laser, needling, tattooing, micropigmentation, threading, waxing. Injured psoriatic skin can raise a fresh plaque exactly where it was broken — the Koebner phenomenon — so the site has to go quiet first, and sometimes the answer stays no
• Gel and acrylic nails over an affected nail; they worsen the lifting that is already there
• Acitretin, the oral retinoid used in psoriasis, for anyone pregnant, breastfeeding, or who could become pregnant. It causes serious birth defects, it stays in the body long after the last dose, and blood donation is not allowed during it or for a long period afterwards. The whole decision sits with whoever prescribes and monitors it, under a documented pregnancy-prevention plan
• Methotrexate in pregnancy, and in anyone who could become pregnant or father a child without strict contraception — it causes miscarriage and serious birth defects, which is why the prescriber sets the contraception on both sides and why it is not started casually. It also needs regular monitoring blood tests, and it interacts with medicines as ordinary as some antibiotics and some painkillers, so every doctor and pharmacist who prescribes for you has to be told you are taking it
• Biologic treatment before tuberculosis and hepatitis screening, or any dose of it while an infection is active
• PUVA in pregnancy and in significant liver disease; and any phototherapy course before the medicines that raise light sensitivity have been reviewed
• Treating a scaling fold or a thickened nail as fungus without a sample. Steroid-modified tinea looks very similar in the groin and underarm, and nail psoriasis is called fungus constantly — a skin scraping or a nail clipping settles it before a long oral course begins
• A request to laser away the pale or dark marks while the plaques are still active. Those marks are the footprint of the inflammation and even out on their own over months; treating them now adds risk and corrects nothing

Possible effects

Stated in full, because the decision is not sound without them:

• Topical corticosteroids used long and unsupervised: thinning skin, stretch marks, visible vessels. It shows on the face, the folds and genital skin before anywhere else, which is why potency is limited there and steroid-sparing options carry most of that plan. Spread strong and wide enough, enough of it is absorbed to behave like a tablet — which is why a wide-area steroid is stepped down rather than stopped in one day
• Unlabeled mixed creams. Many people arrive having used one for months, and it usually contains a steroid of unknown type and strength; skin thinned underneath it bruises, heals and scars unpredictably. Bring the container with you
• Vitamin D analogues sting and irritate, most noticeably on the face and in the folds. Where irritation is the limiting factor the plan is changed rather than pushed through
• Phototherapy: burning if the dose escalates too quickly, eye protection and genital shielding as standard, and cumulative exposure recorded over time. PUVA raises long-term skin cancer risk, so its lifetime dose is tracked — and after an oral psoralen tablet the eyes stay light-sensitive for the rest of that day, so the protective glasses are worn after you leave, not only in the cabin
• Systemic medicines: methotrexate needs regular blood tests that watch the liver and the blood count, and strict contraception in both sexes as the prescriber advises, because it causes miscarriage and serious birth defects. Biologics are preceded by tuberculosis and hepatitis screening, and infection is watched for afterwards
• Nail treatment is slow by nature because it follows nail growth; this is said before it starts, not after, and the nail may not return to exactly its old shape
• After a plaque clears, a pale or dark patch stays behind and takes months to even out. It is the footprint of the inflammation: not a scar, and not vitiligo
• On the scalp, forceful scale removal and tight styles both worsen shedding. Hair usually returns where the loss was from scale and scratching, but a scarring alopecia is excluded by examination before anyone reassures you
• The severe flare that follows abrupt withdrawal of a systemic steroid — described in the box above, and the same reason we do not use one here

A note on darker skin

Recognizing psoriasis on darker skin differs from the textbook picture at almost every point. A plaque tends to look violaceous, gray-brown, or simply darker than the skin around it rather than salmon-pink, so the inflammation is there but does not read as red to the eye; the scale is thicker; and the extent of disease is routinely judged to be less than it is — which delays treatment rather than meaning the disease is milder. What clears leaves a pale or dark patch that is more pronounced and lasts months on deeper skin, and it is mistaken for vitiligo or for a new problem often enough to be worth naming at the first visit: it is not a scar, and it evens out. On the treatment side, skin tone is not a reason to avoid ultraviolet — narrowband UVB is used across all skin types, and the 308 nm excimer is aimed at one patch. But Fitzpatrick IV-VI skin needs a higher dose, burning is possible if the dose escalates too quickly, and a burn on deeper skin leaves pigmentation of its own, so wherever the course is run — and phototherapy is often a referral, because not every clinic has a unit — it is built gradually and the cumulative dose is recorded. The other side of the same coin: any elective laser or needling over an involved site carries two risks at once — the Koebner phenomenon and post-inflammatory pigmentation — which is why it waits.

Afterwards

• Use what you were given for the period you were given, on the sites you were shown. Do not stop a wide-area topical steroid all at once — you are shown how to step it down
• Emollient daily, on quiet skin as much as on scaly skin. Most of the long quiet periods are won here rather than during the flares
• Report joint symptoms the day they start, not at the next visit: morning stiffness lasting more than half an hour, a whole finger or toe swollen rather than one joint, pain at the heel or behind the ankle, and low back pain that eases as you move and wakes you in the second half of the night. Damage from untreated psoriatic arthritis does not reverse, which is why it is asked about at every visit
• Tell us about any cortisone tablet or injection you are given anywhere, for anything — the skin, the chest, a joint — and about any new regular medicine you start, because a few of them wake psoriasis up. And if you are on methotrexate or a biologic, a fever, a sore throat that is not settling, mouth ulcers or any infection that is getting worse is assessed the same day rather than waited out — tell whoever sees you which medicine you are on
• Photograph a flare on your phone while it is at its worst. The day the appointment falls is often a quiet day, and the photograph is the evidence
• Come back while it is quiet too, not only when it is bad. The quiet visit is also where metabolic risk is reviewed — blood pressure, sugar, lipids and weight — because those travel with psoriasis

Honestly

Psoriasis is lifelong and relapsing; treatment aims at control and at long quiet periods, and the pale or dark patches left after a plaque clears take months to even out. Joint pain is asked about at every visit because damage from untreated psoriatic arthritis does not reverse, and extensive or joint-involved disease belongs on a monitored systemic pathway, not in a cosmetic room.

Common questions

See also

Vitiligo treatment, Seborrheic dermatitis, Urticaria (hives), Skin infections