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Health Protocols


Conventional Treatment

An integrated approach to the diagnosis and treatment of psoriasis, with emphasis on comprehensive screening and aggressive treatment of associated conditions (particularly cardiovascular), is important (Ryan 2015; Ni 2014; Padhi 2013; Siegel 2013; Spah 2008). Combining various treatments—topical, phototherapy, systemic drugs—allows lower dosages of each and can improve treatment effectiveness (NIH 2013; UMMC 2014a).

The goals of treatment are to minimize psoriasis symptoms, improve the patient’s quality of life, and achieve and maintain remission with minimal adverse effects (Usatine 2013; Armstrong 2014; AAD 2015).

Typically, treatment options fall into one of three categories (Armstrong 2014; Usatine 2013):

  • Topical: first-line treatment for mild-to-moderate psoriasis
  • Systemic medications: affect the whole body; used for more severe forms of psoriasis
  • Phototherapy: light therapy for moderate-to-severe psoriasis

Topical Therapy

Topical treatments applied directly to plaques include medicated creams, ointments, and lotions. They are usually the first treatment given when psoriasis is diagnosed, and are often combined with stronger therapies (NIH 2013; UMMC 2014a). Topical therapies include:

Table 3: Topical Therapies

Topical Therapies



Cornerstone of psoriasis treatment, especially for mild disease; examples are hydrocortisone and betamethasone; reduce inflammation, slow cell growth, and relieve itching; often combined with other medications, especially vitamin D analogs

Vitamin D analogs

Synthetic forms of vitamin D such as calcipotriene induce normal growth of skin cells; more effective for body and scalp psoriasis when combined with topical corticosteroids

Tar products (including Goeckerman regimen)

Reduces inflammation and slows cell growth; most effective when combined with UVB light; use has declined in part due to historical and disputed safety concerns about cancer, and the time and labor-intensive nature of treatment


Anti-inflammatory, slows cell growth; rarely used due to skin irritation and staining, but may be useful when combined with phototherapy


Synthetic form of vitamin A for mild psoriasis; more effective when combined with corticosteroids or other treatments

Calcineurin inhibitors

Alternative to topical steroids for face and other sensitive regions such as the genitals because they do not cause skin atrophy, but less effective; examples are tacrolimus and pimecrolimus; may be associated with increased risk of skin cancer and lymphoma

Occlusive tapes or dressings

Some topical medications, especially corticosteroids, may be applied by means of a tape or dressing that is often left on overnight

Keratolytic agents

Examples include salicylic acid, alpha-hydroxy acids; mechanisms not completely understood, but may modulate pH of outer layer of skin (stratum corneum) and reduce keratinocyte-keratinocyte adhesion, helping facilitate natural cell shedding; extensive use can cause side effects as a consequence of systemic absorption (eg, ringing in the ears, headache, dizziness); should not be applied to more than 20% of body surface area; sometimes combined with topical steroids

(Dawn 2006; Pearce 2006; Usatine 2013; UMMC 2014a; NIH 2013; Schalock 2014; Ferri 2015; Roelofzen 2010; Armstrong 2014; Wang, Lin 2014; Federman 1999; Chiricozzi 2012; Pittelkow 1981; Menter 1983; Stern 1980)


Phototherapy, or light therapy, is a commonly used and effective psoriasis treatment generally reserved for patients with moderate-to-severe psoriasis (Armstrong 2014). Exposing the skin to ultraviolet light helps control psoriasis by several mechanisms, including destruction of skin-infiltrating T cells, suppression of elevated inflammatory cytokines, and alteration of gene expression (Wong 2013; Furuhashi 2013). Phototherapy can be administered as ultraviolet A (UVA) light in combination with medications, or as variations of ultraviolet B (UVB) light with or without medications (Koo 2000; NIH 2013; UMMC 2014a; Luftl 1998; Schalock 2014).

The benefits of phototherapy can also be obtained naturally through controlled exposure to sunlight, which contains both UVA and UVB (Brenner 2008; Søyland 2011) (see “Dietary and Lifestyle Considerations”).

Ultraviolet B (UVB) phototherapy. There are two types of UVB phototherapies: narrowband and broadband.

  • Narrowband UVB is the most commonly used phototherapy for psoriasis as it has the best risk-benefit ratio compared with other types of light therapy (Usatine 2013; NIH 2013).
  • Broadband UVB has been used for psoriasis for decades. However, it is not as potent as narrowband UVB or UVA, and is not typically helpful for chronic psoriasis (NIH 2013; Kirke 2007; Usatine 2013).

Psoralens and ultraviolet A (PUVA) phototherapy. PUVA therapy is a combination treatment of a medication called psoralen and UVA radiation. Psoralens (eg, 8-methoxypsoralen, or methoxsalen) are photosensitizing agents that make the skin more sensitive to light. These agents interact with DNA and reduce DNA synthesis upon exposure to UVA, leading to reduced proliferation of skin cells (Stern 2007). PUVA therapy is effective in clearing psoriasis in more than 85% of cases. However, long-term use may increase the risk of squamous cell skin cancer and melanoma (Archier 2012). PUVA usually requires a specialty clinic or hospital, and involves treatment two to three times per week. This treatment can lead to redness, burning and blistering, particularly if dosage is not correctly controlled; it also ages skin, termed “skin photoaging” (Naldi 2009; Tahir 2004; Schalock 2014; Armstrong 2014; NIH 2013; Ferri 2015; HQO 2009).

Goeckerman Therapy

Developed in 1925, the Goeckerman regimen consists of the application of crude coal tar combined with exposure to UVB light. The coal tar makes the skin more responsive to the UVB light (Dennis 2013; Gupta 2013; IFPMA 2015). It has been demonstrated in moderate-to-severe psoriasis to be as effective as conventional psoriasis therapy with lower expense, and to improve overall quality of life and reduce emotional distress (Chern 2011).

In one study, all 300 patients treated with the Goeckerman regimen reported 90% or more clearing of psoriatic lesions (Menter 1983). In another study, a 75% improvement in the Psoriasis Assessment Severity Index (PASI) was achieved in 25 patients receiving Goeckerman therapy over a 3-month period, with 95% of patients reaching this level of improvement after just two months. This compares favorably with the 67‒68% reported efficacy of new biologic response modifiers (Lee 2005; Gupta 2013).

Efficacy of Goeckerman therapy tends to manifest rapidly, while the duration of remission experienced by patients is often quite long—anywhere from 9.5 months to over a year. Patients with recurrent psoriasis often repeat the regimen at yearly or longer intervals (Gupta 2013).

The Goeckerman regimen is somewhat controversial, however, as some evidence suggests this treatment may by genotoxic (Fiala 2006) and a 1980 study showed a small increase in skin cancer risk (though the authors themselves said the benefits outweighed the risks) (Stern 1980). On the other hand, multiple more-recent clinical studies did not show an increased risk of cancer from Goeckerman treatment, even in those using crude coal tar for long periods of time (van Schooten 1996; Pittelkow 1981; Roelofzen 2010). In fact, compared to oral systemic agents such as methotrexate and biologics, Goeckerman therapy may have a favorable safety profile, and side effects are generally minimal (Gupta 2013; Roelofzen 2010; Pittelkow 1981).

The long treatment time and labor-intensive nature of the Goeckerman regimen remain impediments to its widespread adoption (de Miguel 2009).

Systemic Medications

Systemic oral or injectable drugs may be prescribed for more severe forms of psoriasis (Armstrong 2014).

Methotrexate. Methotrexate (Trexall) is a first-line systemic drug used to treat adults with severe psoriasis and psoriatic arthritis whose condition has not responded to topical treatments or phototherapy. The drug slows turnover of skin cells by inhibiting the metabolism of folate, a B vitamin necessary for normal cell metabolism, differentiation, and division (Bailey 1999; Gold Standard 2015; Higdon 2014a). It also has immunosuppressive and anti-inflammatory properties. Methotrexate can cause liver damage and decrease production of red blood cells, white blood cells, and platelets (Kozub 2011; Schalock 2014; Armstrong 2014; NIH 2013).

Retinoids. Retinoids are related chemically to vitamin A. They help regulate growth of skin cells. Retinoid drugs include acitretin (Soriatane) and isotretinoin (Accutane). Retinoids can be effective in severe adult psoriasis that does not respond to other therapies, and are sometimes combined with other treatments. Oral retinoids should not be used by women who are pregnant or may become pregnant since they may cause birth defects (Schalock 2014; Armstrong 2014; NIH 2013).

Cyclosporine. Cyclosporine rapidly suppresses the immune system and slows the growth of skin cells. It powerfully suppresses the immune system and is often used to prevent graft rejection in organ transplant recipients. Cyclosporine is generally reserved for short-term “rescue” use to bring very severe and extensive psoriasis under control; long-term use can cause significant adverse effects including kidney problems, hypertension, and non-melanoma skin cancers (Paul 2003; Armstrong 2014; Schalock 2014; NIH 2013).

Apremilast. Apremilast (Otezla) is an oral anti-inflammatory drug that is approved by the Food and Drug Administration (FDA) for plaque psoriasis and psoriatic arthritis (FDA 2014; Fala 2015). Although the exact mechanism of apremilast’s anti-psoriasis activity remains unclear, this medication inhibits an enzyme called phosphodiesterase 4. By doing so, apremilast appears to interrupt the production of numerous proinflammatory cytokines, including tumor necrosis factor-alpha (TNF-α), that are elevated in psoriasis. Apremilast was the subject of two randomized controlled trials in which it was superior to placebo for the treatment of psoriasis. Its side effect profile includes depression, suicidal thoughts, fatigue, and insomnia (Zerilli 2015; Paul 2015; Papp 2015).

Biologic response modifiers . Biologic response modifiers, or biologics, are protein-based drugs. They are given by subcutaneous injection or intravenous infusion. Unlike traditional systemic drugs that suppress the entire immune system, biologics target specific parts of the immune system. Biologics are highly effective in treating moderate-to-severe psoriasis, and are FDA approved for treating plaque psoriasis. These drugs can increase risk of serious infection and cancer (NIH 2013; UMMC 2014a; NPF 2015b), but they are less toxic than traditional systemic therapies (Declercq 2013; Mansouri 2015). Examples of biologics used in the treatment of psoriasis include adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), ustekinumab (Stelara), and secukinumab (Cosentyx) (Armstrong 2014; Schalock 2014; NPF 2015b; Usatine 2013; Sanford 2015; FDA 2015; Bagel 2012).