Psoriasis is a skin condition with different classifications that all involve an autoimmune response. It can differ in type, site, and severity. And like other autoimmune diseases and disorders, there’s no one-size-fits-all course of treatment.
This can make it challenging to find a treatment that works for you. You may also find that your treatment becomes less effective over time. Why does this happen, and what can you do to maintain control over your condition?
Why do treatments stop working?
There are several common reasons why a psoriasis medication may stop working or may not be as effective at controlling your symptoms. They include:
- Drug resistance. With topical treatments, your body can develop a tolerance, referred to commonly as tachyphylaxis. And the body can actually create antibodies to respond to systemic medications. When this happens, you’ll need to find another treatment option.
- Skin infection. Skin infections can slow down treatment progress and some psoriasis medications can actually make an infection worse. If you have any signs of an infection, such as crust or oozing, see your doctor right away.
- Misdiagnosis. Infections, eczema, and contact dermatitis can closely mimic psoriasis. If you’re not responding to treatment or yours stops working, it’s a good idea to ask your doctor if this is a possibility.
- Missed doses. There are lots of reasons why you might miss a dose or two of your medication. Some treatments can withstand the occasional skip, but others rely on steady and consistent use. If you often forget to take your medication, try using an app or calendar tool that sends a reminder when it’s time for that day’s dose. If cost is an issue, talk to your doctor about drug discount programs or alternative treatment methods.
- Stress. Psoriasis flare-ups can be triggered by stress, so finding ways to successfully manage it can make a big difference in your skin — and your life!
Common psoriasis treatments
Here are some current psoriasis treatment options, and some reasons why they may or may not be working for you.
Topical treatments are best for treating mild to moderate psoriasis. They include corticosteroids and non-steroid treatments.
When used alone or with vitamin D, topical corticosteroids are effective in treating localized psoriasis. One downside of using corticosteroids is that they can cause thinning of the skin. They may also stop working over time as the body develops a resistance to the treatment.
There are several types of topical corticosteroids, so talk to your doctor about which one may be right for you. Over-the-counter ointments are available for reducing mild itching and inflammation. If your psoriasis doesn’t respond, your doctor may prescribe something stronger.
Non-steroid topical treatment
Non-steroid treatments include topical retinoids, coal tar, vitamin D analogues, and several prescription treatments. These are also prone to lose their effectiveness over time.
Topical retinoids are vitamin A derivatives that can help reduce inflammation and how often skin cells develop and regrow. They greatly increase the skin’s sensitivity to light, so a UV-blocking sunscreen is a must when going outdoors.
Coal tar is considered highly effective and has been used to treat psoriasis for more than 80 years. It’s often used along with UV therapy. It’s considered especially effective for scalp psoriasis, palmoplantar psoriasis, and localized, chronic plaque psoriasis. Some people may not find coal tar as appealing as other treatments because of its strong odor and staining properties. It’s not recommended for women who are pregnant or breastfeeding.
Vitamin D analogues mimic vitamin D and are used to slow down the growth of new plaque cells. Widely used prescription drugs include calcipotriene and calcitriol.
Anthralin also helps slow skin cell growth and can remove scales and make skin smoother. It’s sometimes irritating to the skin and stains easily. It’s typically applied only for brief periods and then cleaned off.
Calcineurin inhibitors like tacrolimus and pimecrolimus reduce inflammation and plaque buildup. They’re not recommended for long-term use because of the increased risk of skin cancer and lymphoma.
Salicylic acid is available over the counter and by prescription. It encourages the sloughing of dead skin cells and can reduce scaling. It’s often used in combination with other topical medications. Salicylic acid is found in medicated shampoos and scalp solutions to treat scalp psoriasis.
Dithranol, also known as anthralin, is a popular topical treatment for psoriasis. You can apply it as a mixed paste or directly for short contact in higher concentrations. Side effects are mild and can include skin irritation and staining.
When used consistently, phototherapy can be successful in treating psoriasis. Phototherapy options include:
- natural sunlight
- ultraviolet B (UVB)
- ultraviolet A (UVA)
- Goeckerman therapy, which combines coal tar and UVB treatments
- laser treatments
UVA can be very effective when combined with a drug called psoralen. The combination treatment is known as PUVA. Phototherapy, however, is not for everyone. If your skin is sensitive to light or if you have a family history of skin cancer, phototherapy might not be right for you.
Oral and injected drugs, also called systemic drugs, are often used for severe and resistant psoriasis. Some have severe side effects, however, and are typically only given for a short time. They’re also prone to lose their effectiveness as the body develops antibodies to counter them. These drugs include methotrexate, oral retinoids, and cyclosporine.
Methotrexate is FDA approved to treat many diseases including psoriasis. It can be very effective and is not as expensive as other treatments. But it shouldn’t be taken for long periods of time, as the potential side effects can be severe. These can include liver toxicity and damage and reduced production of blood cells and platelets. Your doctor might start you on folic acid to reduce your risk of damage.
Oral retinoids are prescription drugs that mimic vitamin A. They’re only used when the body doesn’t respond to other treatments. Currently, acitretin is the only FDA-approved oral retinoid for psoriasis.
Possible side effects include swelling of the lips and hair loss. Acitretin also isn’t recommended for women who are pregnant or may become pregnant within three years after treatment because it can cause severe birth defects.
Cyclosporine is an immunosuppressant. It’s an oral medication that’s most effective when used short-term. While similarly effective to methotrexate, the side effects can be more severe. This can include increased risk for infection and susceptibility to disease, including cancer.
Biologics work by directly altering the immune system. These biologics are FDA approved to treat moderate to severe psoriasis:
- infliximab (Remicade)
- adalimumab (Humira)
- etanercept (Enbrel)
- ustekinumab (Stelara)
- apremilast (Otezla)
- ixekizumab (Taltz)
- secukinumab (Cosentyx)
- abatacept (Orencia)
- guselkumab (Tremfya)
Biologics have a strong effect on the immune system and may create an increased risk for infections to develop. For this reason, they’re generally used a last resort for treatment. The body may also develop a resistance to them over time.
According to a preclinical study, small molecules can treat psoriasis in people who aren’t responding well to traditional treatments. Apremilast (Otezla) is a new small molecule pill that can help control active psoriatic arthritis or plaque psoriasis.
Finding the right treatment for your psoriasis may take some time, but it’s possible. Make an appointment with your doctor if you think your current treatment is no longer working. Discuss the reasons why your treatment isn’t working and which alternative treatment options are a good fit for you.