Plaque Psoriasis Medication

Updated: Mar 17, 2021
  • Author: Harvey Lui, MD, FRCPC; Chief Editor: Dirk M Elston, MD  more...
  • Print
Medication

Medication Summary

Drug therapy for psoriasis may involve topical and systemic medications in conjunction with phototherapy and moisturizers.

Next:

Corticosteroids, Topical

Class Summary

Topical corticosteroids are the mainstay of treatment for mild and limited psoriasis. They can reduce plaque formation. These agents have anti-inflammatory effects and may cause profound and varied metabolic activities.

Triamcinolone topical (Kenalog topical, Pediaderm TA)

Triamcinolone treats inflammatory dermatosis responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. It has mild potency and is the first drug of choice for most patients.

Betamethasone topical (Diprolene, Luxiq)

Betamethasone treats inflammatory dermatosis responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability. It is a potent topical steroid and is the drug of choice if psoriasis is resistant to milder forms.

Halobetasol (Bryhali, Lexette, Ultravate)

Halobetasol is available in lotion and foam preparations for the treatment of plaque psoriasis.

Previous
Next:

Antipsoriatics, Topical

Calcitriol topical (Vectical)

Calcitriol is a topical vitamin D analog similar to calcipotriene but seems to be less irritating in sensitive areas of skin.

Calcipotriene (Calcitrene Ointment, Dovonex, Sorilux)

Calcipotriene is a synthetic vitamin D-3 analog that regulates skin cell production and development. It is used in the treatment of moderate plaque psoriasis. This treatment does not cause long-term skin thinning or systemic effects. Sorilux is a newer foam version of this medication.

Calcipotriene/betamethasone (Enstilar, Taclonex Ointment, Taclonex Topical Suspension, Wynzora)

Calcipotriene is a synthetic vitamin D-3 analog that regulates skin cell production and development. It inhibits epidermal proliferation, promotes keratinocyte differentiation, and has immunosuppressive effects on lymphoid cells. Betamethasone is a corticosteroid that decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. The combination is available as a topical ointment, foam, cream, or as a solution that can be applied to the body or scalp. The products contain calcipotriene 0.005% and betamethasone dipropionate 0.064%.

Tazarotene (Avage, Fabior, Tazorac)

Tazarotene is a retinoid prodrug that is converted to its active form in the body and modulates differentiation and proliferation of epithelial tissue and perhaps has anti-inflammatory and immunomodulatory activities. It may be the drug of choice for those with facial lesions who are not at risk of pregnancy.

Tazarotene, although topical, is a category X medication. Topical tretinoin is of less use in psoriatic patients. A strategy that may be tried in patients who experience unacceptable irritation is to use short contact times. There are several protocols, but the least irritating is to apply the medication for 15-20 min and then wash off. The total time on may be increased by 15-20 minutes every few weeks until clinical efficacy or adverse cutaneous effects are seen. This short-contact method may be especially useful when one is using it in skin folds but is less effective for the plaque with very thick scale.

Previous
Next:

Keratolytic Agents

Class Summary

Keratolytic agents are used to remove scale, to smooth the skin, and to treat hyperkeratosis.

Coal tar topical (Fototar, Medotar, Oxipor VHC)

Coal tar is antipruritic and antibacterial and inhibits deregulated epidermal proliferation and dermal infiltration. It does not injure the normal skin when applied widely, and it enhances the usefulness of phototherapy. It generally is used as a second-line drug therapy owing to messy application, except for shampoos, which may be used and rinsed at once.

Anthralin (Dritho-Scalp)

Anthralin reduces the rate of cell proliferation. Its chemically reducing properties may also upset the oxidative metabolic processes, further reducing epidermal mitosis. It is not the first or second drug of choice owing to irritation problems of normal skin surrounding lesions and staining of the skin.

Previous
Next:

Topical Combinations

Class Summary

Combination topical products with differing mechanisms of actions are available to improve ease of application.

Halobetasol/tazarotene (Duobrii)

Halobetasol is indicated for the treatment of plaque psoriasis in adults. It is  a combination lotion containing a topical corticosteroid and a retinoid.

Previous
Next:

Interleukin Inhibitors

Class Summary

Interleukins (ILs) play key roles in the pathogenesis of plaque psoriasis.

Risankizumab (Skyrizi, risankizumab-rzaa)

Risankizumab is a humanized immunoglobulin G1 (IgG1) monoclonal antibody that selectively binds to the p19 subunit of IL-23 cytokine and inhibits its interaction with the IL-23 receptor. IL-23 is a naturally occurring cytokine that is involved in inflammatory and immune responses. It is indicated for treatment of moderate-to-severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy.

Tildrakizumab (Ilumya, tildrakizumab-asmn)

This humanized IgG1/k monoclonal antibody selectively binds to the p19 subunit of IL-23 and inhibits its interaction with the IL-23 receptor. IL-23 is a natural cytokine associated with inflammatory and immune responses. Tildrakizumab inhibits the release of proinflammatory cytokines and chemokines. It is indicated for adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

Guselkumab (Tremfya)

Guselkumab is a human monoclonal IgG1-lambda antibody that selectively binds to the p19 subunit of IL-23. IL-23 is a natural cytokine associated with inflammatory and immune responses. Guselkumab inhibits the proinflammatory actions of IL-23, thereby decreasing cytokine and chemokine release. It is indicated for adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy.

Ustekinumab (Stelara)

Ustekinumab is a human monoclonal antibody directed against IL-12 and IL-23, thereby interfering with T-cell differentiation and activation and subsequent cytokine cascades. It is indicated for moderate-to-severe plaque psoriasis.

Brodalumab (Siliq)

Brodalumab is a human monoclonal IgG2 antibody that selectively binds to the human IL-17A receptor and inhibits its interactions with cytokines IL-17A, IL-17F, IL-17C, IL-17A/F heterodimer, and IL-25. It is indicated for moderate-to-severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy and have failed to respond or have lost response to other systemic therapies.

Secukinumab (Cosentyx)

Secukinumab is a human IgG1 monoclonal antibody that selectively binds to and neutralizes the proinflammatory cytokine IL-17A. IL-17A is a naturally occurring cytokine that is involved in normal inflammatory and immune responses and plays a key role in the pathogenesis of plaque psoriasis. Following the initial once-weekly SC dosage regimen, the drug is given as a maintenance dose once monthly. It is indicated for moderate-to-severe plaque psoriasis in patients who are candidates for systemic therapy or phototherapy.

Ixekizumab (Taltz)

Ixekizumab is a humanized monoclonal IgG4 antibody that targets IL-17A and neutralizes the proinflammatory effects of IL-17A. It is administered as a SC injection. It is indicated for adults with moderate-to-severe plaque psoriasis.

Previous
Next:

DMARDs, PDE4 Inhibitors

Class Summary

The mechanisms by which phosphodiesterase-4 (PED4) inhibitors elicit anti-inflammatory effects are not completely understood. Unlike biologics that neutralize inflammatory mediators at the protein level, apremilast modulates mediator production at the level of mRNA expression.

Apremilast (Otezla)

Apremilast is a phosphodiesterase-4 inhibitor specific for cAMP, resulting in increased intracellular cAMP levels. It may affect cytokines and chemokine synthesis, leading to anti-inflammatory effects. It is indicated for moderate-to-severe plaque psoriasis in adults who are candidates for phototherapy or systemic therapy.

Previous
Next:

Immunosuppressants

Methotrexate (Otrexup, Rasuvo, Trexall)

Methotrexate inhibits dihydrofolic acid reductase. Dihydrofolates must be reduced to tetrahydrofolates by this enzyme before they can be utilized as carriers of one-carbon groups in the synthesis of nucleotides and thymidylate. Subsequently, methotrexate interferes with DNA synthesis, repair, and cellular replication. Actively proliferating tissues are in general more sensitive to this effect of methotrexate.

Previous
Next:

Tumor Necrosis Factor Inhibitors

Infliximab (Remicade, Inflectra, Renflexis, Ixifi )

Infliximab is a chimeric antibody that binds both the soluble and transmembrane TNF-α molecules, thereby neutralizing the effects of TNF-α. It is indicated for chronic severe (ie, extensive and/or disabling) plaque psoriasis in adults who are candidates for systemic therapy and when other systemic therapies are medically less appropriate. It is also indicated to reduce signs and symptoms, and to improve physical function of patients with psoriatic arthritis. Screen patients for tuberculosis (TB) and hepatitis B, as reactivation of both illnesses is associated with TNF-α inhibitors.

Adalimumab (Amjevita, Cyltezo, Humira, Hadlima, Hyrimoz, Adalimumab-atto, Adalimumab-adbm, Adalimumab-bwwd, Adalimumab-adaz)

Adalimumab is a fully human anti–TNF-α monoclonal antibody. It binds specifically to soluble and membrane-bound TNF-α, thereby neutralizing the effects of TNF-α. It is used to treat moderate-to-severe psoriasis and moderate-to-severe psoriatic arthritis. Screen patients for TB and hepatitis B, as reactivation of both illnesses is associated with TNF-α inhibitors. The FDA approved adalimumab-atto, adalimumab-adbm, adalimumab-adaz, and adalimumab-bwwd as biosimilars and not as interchangeable drugs.

Etanercept (Enbrel, Eticovo)

Etanercept is a recombinant human TNF-α receptor protein fused with the Fc portion of IgG1 that binds to soluble and membrane-bound TNF-α, thereby neutralizing the effects of TNF-α. It is indicated for adults and children aged 4 years and older with moderate-to-severe psoriasis. It is also indicated for adults with moderate-to-severe psoriatic arthritis. Screen patients for TB and hepatitis B, as reactivation of both illnesses is associated with TNF-α inhibitors.

Certolizumab pegol (Cimzia)

Certolizumab pegol is indicated for moderate-to-severe plaque psoriasis. It is a pegylated anti–TNF-α blocker, and its action results in disruption of the inflammatory process.

Previous