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    Understanding Psoriasis

    Celine Mestel, MD, PhD Deaconess Clinic Dermatology 03/12/2023

    Psoriasis is a common chronic skin condition that affects about 1-2% of the population, and is one of the most common diseases that dermatologists treat.  Every patient experiences their psoriasis differently, and depending on the severity of the symptoms, psoriasis can be a mild annoyance or a major cause of disability.

    What causes psoriasis?
    Like most other chronic diseases, psoriasis is understood to be a mix of genetics and environment. Some patients note that family members have the disease as well, and some are the only ones in their family with psoriasis.  Some patients only flare up when they are sick or stressed, and others seem to have symptoms all the time.

    In the past, psoriasis was thought to be a disease of the skin cells, where something was causing them to grow too quickly, leading to the red scaly plaques we are familiar with.  However, our understanding of psoriasis is improving, and we now believe that the problem is caused by abnormal signals sent by immune cells resulting in inflammation throughout the body. Although for most people this inflammation shows up in the skin, in some people (5-30% of psoriasis patients) this shows up in the joints as psoriatic arthritis.  Others, typically those with more severe disease, have an increased risk of cardiac disease.  In fact, severe psoriasis is emerging as a risk factor for heart disease that may be just as significant as diabetes and obesity.

    What are the treatments and therapies for psoriasis?
    The treatment ladder we use is based on the severity of the symptoms, not just the amount of plaques on the skin.  If a patient has psoriatic arthritis, they are often co-managed with rheumatology specialists; in this case, using only topical therapy is not appropriate even if the skin disease is mild.
    I will review some of the more common treatments below.  Your dermatologist will let you know if a treatment is appropriate for you:

    Mild disease

    • Topical steroids are still the mainstay of mild skin-only disease and are usually quite effective when used regularly
    • Topical vitamin D analogs (eg. calcipotriene) work in a different way than topical steroids and are often used together


    • Ultraviolet light in a special UV booth at the doctor’s office can be very safe and effective
    • Acitretin (Soriatane) is a pill that requires some laboratory monitoring and has some known side effects but is usually well tolerated.
    • Apremilast (Otezla) is a relatively new pill that works by blocking an enzyme and reducing inflammation.  It has some mild side effects but does not require laboratory monitoring.

    Moderate-to Severe

    • Injectable or infusible medications known as “biologics” have revolutionized both psoriasis and psoriatic arthritis treatment and have been able to make patients with severe disease mostly or totally clear.  These include etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), ustekinumab (Stelara), secukinumab (Cosentyx), and ixekizumab (Taltz). New medications of this kind are coming to market soon. All of these target different parts of the immune system, and because of this, have increased risk of infection and cancer.
    • Methotrexate is an older oral medication that is very effective for psoriasis but has some health restrictions and requires laboratory monitoring.

    How to take care of your skin at home

    • Moisturize! Keeping your skin hydrated is key to reducing itching and redness, and thinning out the scales.  Use fragrance-free creams or ointments and apply within a few minutes of bathing to lock the moisture in.
    • Get some sun! If your doctor says it is appropriate for you, 10-15 min per day of direct sunlight to affected areas can improve psoriasis·          
    • Decrease stress! Although easier said than done, stress is known to flare psoriasis

    The last point I want to stress is that psoriasis is a chronic disease and although we have made a lot of progress in treatment, as of yet there is no cure.  It is important to realize that if you stop your medication, the symptoms will likely return.  Your dermatologist will work with you to keep you on the smallest amount of medicine that will keep you comfortable and your skin looking great!

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