Treatment Pathway for Plaque Psoriasis
This psoriasis treatment pathway is an example of the typical progression through the types of psoriasis treatments available. It will be dependent on the patient's severity of disease, impact on quality of life and treatment preferences, along with the treating prescriber's individual approach. It is important to talk to your GP or dermatologist regarding which psoriasis treatments may be suitable for you.
The earlier you see your GP and get a diagnosis, the earlier treatment can start. So, if you recognise any of the symptoms listed on this site, talk to your GP.
Most patients attribute their rashes to other causes prior to diagnosis. This can leave them feeling frustrated and confused. It is important to see your GP if you notice any signs of psoriasis so you can start treatment earlier and maintain your normal life.
Treatment typically starts from the outside then works inwards. The first step is usually topical treatments, and is likely to be given by your GP. Topical treatments include creams, ointments and lotions that are applied directly to your skin, some of which can be purchased directly from the pharmacy while others are available by prescription only.
They are usually the first treatment used for psoriasis and are typically given when psoriasis is mild. These treatments slow down the growth of skin cells, and reduce the redness and swelling (inflammation) associated with psoriasis. A wide range of topical psoriasis treatments are available, some of which can be purchased directly from the pharmacy while others are available by prescription only. Topical treatments include:
- salicylic acid
- vitamin D analogues (such as calcipotriol)
- vitamin A analogues (such as tazarotene)
- coal tar extracts
- anthralins (such as dithranol)
and a combination of any of these agents.
If topical treatments fail, your GP will probably refer you to a dermatologist who is specially trained to treat psoriasis. They may try other topical creams and ointments or combinations to see how you respond to treatment.
Failure of topical treatments often leaves patients feeling frustrated and depressed. It is important to remember that this is not uncommon. If you have tried multiple topical treatments and you haven’t seen a difference, you may wish to talk to your GP or dermatologist about trying a different type of treatment.
Your GP or dermatologist can prescribe a range of topical treatments. Depending on the type of topical treatment, you may expect to see a difference in a few weeks. Your progress will be monitored every few weeks by your doctor. It is important to tell your GP or dermatologist if you are using any other treatments or dietary supplements as these may interfere with how the prescribed treatment works.
Tips for using topical treatment
- Read the Consumer Medicine Information leaflet provided with your topical treatments to ensure you understand exactly how much you should use.
- Apply only to affected areas if possible to avoid irritating unaffected skin.
- When using multiple topical treatments, ask your doctor which order to apply them.
- Do not overuse topical steroid treatments as they can be absorbed into the body.
Consult your GP or dermatologist if you experience any unusual discomfort.
Topical treatments are the mildest of the treatments available for psoriasis, which is why they are generally tried first. However, there are a large number of topical treatments and these vary in strength. The side effects depend on which one you are using and how strong it is. Speak to your doctor or read the Consumer Medicine Information leaflet that comes with your prescription for further information on side effects specific to your treatment.
Light therapy, also known as phototherapy, involves exposing the skin to artificial ultraviolet light on a regular basis and under medical supervision. It uses ultraviolet light (UVB or psoralen and UVA), which slows the growth of affected skin cells. Light therapy is generally used to treat widespread psoriasis.
Psoralen is a pill, lotion or bath salt that increases the skin’s sensitivity to UV light.
Light therapy can only be prescribed by a dermatologist. Partial to full skin clearing can occur after an average of 20 clinic treatments (up to 3 months). It is important to tell your dermatologist if you are using any other medicines or dietary supplements prior to initiating light therapy as some medicines and herbal products can increase sensitivity to light.
In Australia, light therapy is available at some hospitals, Skin and Cancer Foundation clinics and at some dermatologist’s offices.
Light therapy is associated with side effects that usually result from too much exposure to sunlight. The side effects will vary depending on the type of light therapy you are using. Your dermatologist will be able to tell you more about the potential side effects of light therapy and the precautionary measures you can take to reduce your chance of experiencing them.
Systemic treatments work on the entire body (system). They target your immune system and ultimately slow the growth of skin cells. Systemic treatments can be taken by mouth or injected into the body. These treatments are typically prescribed when patients have moderate-to-severe psoriasis, or when topical treatments and light therapy have failed. There are a range of systemic treatments available, some of which can be prescribed by your GP and some that will require referral to a dermatologist. Treatments include acitretin, cyclosporin and methotrexate.
Some of these treatments will work faster than others. You may expect to see a difference anywhere between 3 weeks to 4 months. It is important to tell your dermatologist if you are using any other medicines or dietary supplements prior to initiating systemic treatments as these may interfere with how the prescribed treatment works.
Systemic treatments are associated with a larger number of side effects than topical treatments. For this reason, your GP or dermatologist will most likely try topical treatments and light therapy before prescribing a systemic treatment. The side effects will vary depending on which treatment you have been prescribed. It is important to see your GP or dermatologist if you experience any side effects. Speak to your doctor or read the Consumer Medicine Information leaflet that comes with your prescription for further information on side effects specific to your treatment.
Biologic treatments for Plaque Psoriasis
Biologic treatments (biologics) are injected into the body, either just under the skin (subcutaneous) or as an intravenous infusion. Like traditional systemic treatments, biologics target your immune system; however, biologics are much more specific. Biologics are reserved for people with moderate-to-severe plaque psoriasis and when other treatments are not working, as certain criteria have to be met before these treatments are subsidised by the Pharmaceutical Benefits Scheme PBS.
The Pharmaceutical Benefits Scheme (PBS) provides affordable access to necessary treatments for Australians. The PBS Schedule lists all of the treatments to be dispensed to patients at a Government-subsidised price.
It is important to remember that your dermatologist is required to have tried all other approaches prior to biologic treatment, as this is one of the criteria for obtaining your treatment at a subsidised price (PBS subsidy).
Biologic treatments include adalimumab, etanercept, infliximab and ustekinumab. Biologics can only be prescribed by your dermatologist. It is important to tell your dermatologist if you are using any other treatments or dietary supplements as these may interfere with how the prescribed treatment works.
There is much information available on the safety of biologics which can be provided by your dermatologist. As biologics work in a different way to other systemic treatments, they may be associated with different side effects. The side effects will vary depending on the treatment you have been prescribed. It is important that the benefits of treatment are weighed against the risks. Speak to your doctor or read the Consumer Medicine Information leaflet that comes with your prescription for further information on side effects specific to your treatment.
Eligibility for a biologic treatment
The PBS has specific criteria you must meet to qualify for biologic treatment. For example, you must have severe chronic plaque psoriasis with:
Lesions for at least six months with a PASI score of >15
The severity of psoriasis is measured with the Psoriasis Area and Severity Index (PASI) score. It is a scale that takes into account the area of lesion coverage (calculated as the percentage of the affected body surface area) as well as plaque appearance (redness, thickness and scaling). A PASI score of:
- ≤10 suggests mild psoriasis
- >10 suggests moderate-to-severe psoriasis
- Lesions on the face, palm of a hand or sole of a foot and severe/very severe reddening of the skin, thickness and scaling for at least six months
- Lesions that affect >30% of the face, palm of a hand or sole of a foot for at least six months (1% of your body is approximately the same area as the surface of your palm)
Plus, in addition to the above, you must have failed other therapies, including phototherapy and other systemic treatments, before eligibility for these treatments on the PBS.
What happens if I don’t respond to treatment?
By the time you get to try a biologic, you will have tried and failed numerous treatments. If your first biologic treatment fails you may feel like you are out of options. However, not everyone responds to all treatments in the same way and if you don’t respond to your first therapy, according the PBS criteria, you have up to 2 alternative biologics that you are able to try.
However, if your biologic treatment fails, or you don’t respond to treatment 3 times, you are classified as completing a single cycle, and must have at least a 5-year break before recommencing PBS-reimbursed biologic therapy.