Diagnosis and treatment - Mayo Clinic https://www.mayoclinic.org/diseases-conditions/psoriasis/diagnosis-treatment/drc-20355845?

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Psoriasis
Diagnosis
In most cases, diagnosis of psoriasis is fairly straightforward.

Physical exam and medical history. Your doctor usually can diagnose psoriasis by taking your medical history and examining your skin, scalp and nails.
Skin biopsy. Rarely, your doctor may take a small sample of skin (biopsy). He or she will likely first apply a local anesthetic. The sample is examined under a
microscope to determine the exact type of psoriasis and to rule out other disorders.

Treatment
Psoriasis treatments reduce inflammation and clear the skin. Treatments can be divided into three main types: topical treatments, light therapy and systemic medications.

Topical treatments
Used alone, creams and ointments that you apply to your skin can effectively treat mild to moderate psoriasis. When the disease is more severe, creams are likely to be
combined with oral medications or light therapy. Topical psoriasis treatments include:

Topical corticosteroids. These drugs are the most frequently prescribed medications for treating mild to moderate psoriasis. They reduce inflammation and relieve
itching and may be used with other treatments.

Mild corticosteroid ointments are usually recommended for sensitive areas, such as your face or skin folds, and for treating widespread patches of damaged skin.

Your doctor may prescribe stronger corticosteroid ointment for smaller, less sensitive or tougher-to-treat areas.

Long-term use or overuse of strong corticosteroids can cause thinning of the skin. Topical corticosteroids may stop working over time. It's usually best to use topical

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corticosteroids as a short-term treatment during flares.

Vitamin D analogues. These synthetic forms of vitamin D slow skin cell growth. Calcipotriene (Dovonex) is a prescription cream or solution containing a vitamin D
analogue that treats mild to moderate psoriasis along with other treatments. Calcipotriene might irritate your skin. Calcitriol (Vectical) is expensive but may be equally
effective and possibly less irritating than calcipotriene.
Anthralin. This medication helps slow skin cell growth. Anthralin (Dritho-Scalp) can also remove scales and make skin smoother. But anthralin can irritate skin, and it
stains almost anything it touches. It's usually applied for a short time and then washed off.
Topical retinoids. These are vitamin A derivatives that may decrease inflammation. The most common side effect is skin irritation. These medications may also
increase sensitivity to sunlight, so while using the medication apply sunscreen before going outdoors.

The risk of birth defects is far lower for topical retinoids than for oral retinoids. But tazarotene (Tazorac, Avage) isn't recommended when you're pregnant or breast-
feeding or if you intend to become pregnant.

Calcineurin inhibitors. Calcineurin inhibitors — tacrolimus (Prograf) and pimecrolimus (Elidel) — reduce inflammation and plaque buildup.

Calcineurin inhibitors are not recommended for long-term or continuous use because of a potential increased risk of skin cancer and lymphoma. They may be
especially helpful in areas of thin skin, such as around the eyes, where steroid creams or retinoids are too irritating or may cause harmful effects.

Salicylic acid. Available over-the-counter (nonprescription) and by prescription, salicylic acid promotes sloughing of dead skin cells and reduces scaling. Sometimes
it's combined with other medications, such as topical corticosteroids or coal tar, to increase its effectiveness. Salicylic acid is available in medicated shampoos and
scalp solutions to treat scalp psoriasis.
Coal tar. Derived from coal, coal tar reduces scaling, itching and inflammation. Coal tar can irritate the skin. It's also messy, stains clothing and bedding, and has a
strong odor.

Coal tar is available in over-the-counter shampoos, creams and oils. It's also available in higher concentrations by prescription. This treatment isn't recommended for
women who are pregnant or breast-feeding.

Moisturizers. Moisturizing creams alone won't heal psoriasis, but they can reduce itching, scaling and dryness. Moisturizers in an ointment base are usually more
effective than are lighter creams and lotions. Apply immediately after a bath or shower to lock in moisture.

Light therapy (phototherapy)

This treatment uses natural or artificial ultraviolet light. The simplest and easiest form of phototherapy involves exposing your skin to controlled amounts of natural sunlight.

Other forms of light therapy include the use of artificial ultraviolet A (UVA) or ultraviolet B (UVB) light, either alone or in combination with medications.

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Sunlight. Exposure to ultraviolet (UV) rays in sunlight or artificial light slows skin cell turnover and reduces scaling and inflammation. Brief, daily exposures to small
amounts of sunlight may improve psoriasis, but intense sun exposure can worsen symptoms and cause skin damage. Before beginning a sunlight regimen, ask your
doctor about the safest way to use natural sunlight for psoriasis treatment.
UVB phototherapy. Controlled doses of UVB light from an artificial light source may improve mild to moderate psoriasis symptoms. UVB phototherapy, also called
broadband UVB, can be used to treat single patches, widespread psoriasis and psoriasis that resists topical treatments. Short-term side effects may include redness,
itching and dry skin. Using a moisturizer may help decrease these side effects.
Narrow band UVB phototherapy. A newer type of psoriasis treatment, narrow band UVB phototherapy may be more effective than broadband UVB treatment. It's
usually administered two or three times a week until the skin improves, and then maintenance may require only weekly sessions. Narrow band UVB phototherapy may
cause more-severe and longer lasting burns, however.
Goeckerman therapy. Some doctors combine UVB treatment and coal tar treatment, which is known as Goeckerman treatment. The two therapies together are more
effective than either alone because coal tar makes skin more receptive to UVB light.
Psoralen plus ultraviolet A (PUVA). This form of photochemotherapy involves taking a light-sensitizing medication (psoralen) before exposure to UVA light. UVA light
penetrates deeper into the skin than does UVB light, and psoralen makes the skin more responsive to UVA exposure.

This more aggressive treatment consistently improves skin and is often used for more-severe cases of psoriasis. Short-term side effects include nausea, headache,
burning and itching. Long-term side effects include dry and wrinkled skin, freckles, increased sun sensitivity, and increased risk of skin cancer, including melanoma.

Excimer laser. This form of light therapy, used for mild to moderate psoriasis, treats only the involved skin without harming healthy skin. A controlled beam of UVB light
is directed to the psoriasis plaques to control scaling and inflammation. Excimer laser therapy requires fewer sessions than does traditional phototherapy because
more powerful UVB light is used. Side effects can include redness and blistering.

Oral or injected medications

If you have severe psoriasis or it's resistant to other types of treatment, your doctor may prescribe oral or injected drugs. This is known as systemic treatment. Because of
severe side effects, some of these medications are used for only brief periods and may be alternated with other forms of treatment.

Retinoids. Related to vitamin A, this group of drugs may help if you have severe psoriasis that doesn't respond to other therapies. Side effects may include lip
inflammation and hair loss. And because retinoids such as acitretin (Soriatane) can cause severe birth defects, women must avoid pregnancy for at least three years
after taking the medication.
Methotrexate. Taken orally, methotrexate (Rheumatrex) helps psoriasis by decreasing the production of skin cells and suppressing inflammation. It may also slow the
progression of psoriatic arthritis in some people. Methotrexate is generally well-tolerated in low doses but may cause upset stomach, loss of appetite and fatigue. When
used for long periods, it can cause a number of serious side effects, including severe liver damage and decreased production of red and white blood cells and platelets.
Cyclosporine. Cyclosporine (Gengraf, Neoral) suppresses the immune system and is similar to methotrexate in effectiveness, but can only be taken short-term. Like

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other immunosuppressant drugs, cyclosporine increases your risk of infection and other health problems, including cancer. Cyclosporine also makes you more
susceptible to kidney problems and high blood pressure — the risk increases with higher dosages and long-term therapy.
Drugs that alter the immune system (biologics). Several of these drugs are approved for the treatment of moderate to severe psoriasis. They include etanercept
(Enbrel), infliximab (Remicade), adalimumab (Humira), ustekinumab (Stelara), golimumab (Simponi), apremilast (Otezla), secukinumab (Cosentyx) and ixekizumab
(Taltz). Most of these drugs are given by injection (apremilast is oral) and are usually used for people who have failed to respond to traditional therapy or who have
associated psoriatic arthritis. Biologics must be used with caution because they have strong effects on the immune system and may permit life-threatening infections. In
particular, people taking these treatments must be screened for tuberculosis.
Other medications. Thioguanine (Tabloid) and hydroxyurea (Droxia, Hydrea) are medications that can be used when other drugs can't be given.

Treatment considerations
Although doctors choose treatments based on the type and severity of psoriasis and the areas of skin affected, the traditional approach is to start with the mildest
treatments — topical creams and ultraviolet light therapy (phototherapy) — in those patients with typical skin lesions (plaques) and then progress to stronger ones only if
necessary. Patients with pustular or erythrodermic psoriasis or associated arthritis usually need systemic therapy from the beginning of treatment. The goal is to find the
most effective way to slow cell turnover with the fewest possible side effects.

Potential future treatments

There are a number of new medications currently being researched that have the potential to improve psoriasis treatment. These treatments target different proteins that
work with the immune system.

Alternative medicine
A number of alternative therapies claim to ease the symptoms of psoriasis, including special diets, creams, dietary supplements and herbs. None have definitively been
proved effective. But some alternative therapies are deemed generally safe, and they may be helpful to some people in reducing signs and symptoms, such as itching and
scaling. These treatments would be most appropriate for those with milder, plaque disease and not for those with pustules, erythroderma or arthritis.

Aloe vera. Taken from the leaves of the aloe vera plant, aloe extract cream may reduce redness, scaling, itching and inflammation. You may need to use the cream
several times a day for a month or more to see any improvements in your skin.
Fish oil. Omega-3 fatty acids found in fish oil supplements may reduce inflammation associated with psoriasis, although results from studies are mixed. Taking 3
grams or less of fish oil daily is generally recognized as safe, and you may find it beneficial.
Oregon grape. Also known as barberry, topical applications of Oregon grape may reduce inflammation and ease psoriasis symptoms.

If you're considering dietary supplements or other alternative therapy to ease the symptoms of psoriasis, consult your doctor. He or she can help you weigh the pros and

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cons of specific alternative therapies.

Lifestyle and home remedies

Although self-help measures won't cure psoriasis, they may help improve the appearance and feel of damaged skin. These measures may benefit you:

Take daily baths. Bathing daily helps remove scales and calm inflamed skin. Add bath oil, colloidal oatmeal, Epsom salts or Dead Sea salts to the water and soak.
Avoid hot water and harsh soaps, which can worsen symptoms; use lukewarm water and mild soaps that have added oils and fats. Soak about 10 minutes then gently
pat dry skin.
Use moisturizer. After bathing, apply a heavy, ointment-based moisturizer while your skin is still moist. For very dry skin, oils may be preferable — they have more
staying power than creams or lotions do and are more effective at preventing water from evaporating from your skin. During cold, dry weather, you may need to apply a
moisturizer several times a day.
Expose your skin to small amounts of sunlight. A controlled amount of sunlight can improve psoriasis, but too much sun can trigger or worsen outbreaks and
increase the risk of skin cancer. First ask your doctor about the best way to use natural sunlight to treat your skin. Log your time in the sun, and protect skin that isn't
affected by psoriasis with sunscreen.
Avoid psoriasis triggers, if possible. Find out what triggers, if any, worsen your psoriasis and take steps to prevent or avoid them. Infections, injuries to your skin,
stress, smoking and intense sun exposure can all worsen psoriasis.
Avoid drinking alcohol. Alcohol consumption may decrease the effectiveness of some psoriasis treatments. If you have psoriasis, avoid alcohol. If you do drink, keep
it moderate.

Coping and support

Coping with psoriasis can be a challenge, especially if the disease covers large areas of your body or is in places readily seen by other people, such as your face or
hands. The ongoing, persistent nature of the disease and the treatment challenges only add to the burden.

Here are some ways to help you cope and to feel more in control:

Get educated. Find out as much as you can about the disease and research your treatment options. Understand possible triggers of the disease, so you can better
prevent flare-ups. Educate those around you — including family and friends — so they can recognize, acknowledge and support your efforts in dealing with the
disease.
Follow your doctor's recommendations. If your doctor recommends certain treatments and lifestyle changes, be sure to follow them. Ask questions if anything is
unclear.

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Find a support group. Consider joining a support group with other members who have the disease and know what you're going through. You may find comfort in
sharing your experience and struggles and meeting people who face similar challenges. Ask your doctor for information on psoriasis support groups in your area or
online.
Use cover-ups when you feel it necessary. On those days when you feel particularly self-conscious, cover the psoriasis with clothing or use cosmetic cover-up
products, such as body makeup or a concealer. These products can mask redness and psoriasis plaques. They can irritate the skin, however, and shouldn't be used on
open sores, cuts or unhealed lesions.

Preparing for your appointment

You'll likely first see your family doctor or a general practitioner. In some cases, you may be referred directly to a specialist in skin diseases (dermatologist).

Here's some information to help you prepare for your appointment and to know what to expect from your doctor.

What you can do

Make a list of the following:

Symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment
All medications, vitamins, herbs you take, including doses
Questions to ask your doctor

For psoriasis, some basic questions you might ask your doctor include:

What might be causing my signs and symptoms?

Do I need diagnostic tests?
What treatments are available, and which do you recommend for me?
What types of side effects can I expect?
Will the treatment you recommended cause a remission in my symptoms?
How quickly can I expect results?
What are the alternatives to the primary approach you're suggesting?
I have other medical conditions. How can I manage these conditions together?
What skin care routines and products do you recommend to improve my symptoms?

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What to expect from your doctor

Your doctor is likely to ask you several questions, such as:

When did you begin having symptoms?

How often do you have these symptoms?
Have your symptoms been continuous or occasional?
Does anything seem to improve your symptoms?
What, if anything, appears to worsen your symptoms?

By Mayo Clinic Staff

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