From medicaldaily.com
Psoriasis affects about 3.2 percent of adults in the United States, and the people living with it know it's rarely just a skin problem. Good psoriasis care starts with understanding that it's a chronic, immune-driven condition that often reaches beyond the skin. It also means working with a provider who can match treatment to severity over time.
Wm. Philip Werschler, MD is a board-certified dermatologist with more than 30 years of clinical experience and a long record as an FDA clinical trial investigator. He's a founding member of the American Society of Cosmetic Dermatology and Aesthetic Surgery and the founding Editor-in-Chief of the Journal of Clinical and Aesthetic Dermatology (JCAD). Additionally, Dr. Werschler serves as a professor of dermatology at the University of Washington and Washington State University medical schools. During his seasoned career and through extensive research, he has treated thousands of psoriasis patients and shares his expertise on managing the condition.
Understanding Psoriasis as a Chronic Condition
Psoriasis is a chronic immune-mediated disease that's been linked to other health conditions, and managing it well means looking past the visible plaques. The skin changes happen because the immune system tells skin cells to grow far faster than normal. Those cells pile up and form the raised, scaly patches most people know.
Plaque psoriasis is the most common type, making up about 90 percent of cases. Other forms include guttate, inverse, pustular, and erythrodermic psoriasis. Each one looks different and may need a different approach.
Because psoriasis raises the risk of heart disease, obesity, diabetes, and depression, it's treated as a long-term condition rather than something that can be cleared once and forgotten. Flares can come back after months or even years of calm, and triggers shift over a lifetime. Ongoing care, regular skin checks, and teamwork with a primary care provider help patients stay ahead of both the disease and the health risks tied to it.
How Dermatologists Assess Psoriasis Severity
Dr. Werschler explains that specialists most often use the Psoriasis Area and Severity Index, or PASI, to grade severity. PASI measures how much of the body is affected along with the redness, thickness, and scaling of plaques. It sorts cases into mild, moderate, or severe categories.
Severity matters because it shapes which treatments make sense and which therapies insurance will cover. Location of plaques is also a key factor. Plaques on the scalp, nails, palms, soles, or genital area often need a special approach, even when the total skin area involved is small.
A full evaluation also includes screening for psoriatic arthritis, which develops in about one in three people with psoriasis. Joint inflammation can start quietly with stiffness or swelling in the fingers or toes, and untreated psoriatic arthritis can cause permanent joint damage. Catching it early gives patients the best shot at keeping their joints working well.
What Are the Main Treatment Options for Psoriasis?
As Dr. Werschler notes, psoriasis care today includes five main types of treatment: topical therapies, phototherapy, oral medications, injectable biologics, and medicated shampoos for scalp involvement. Most plans incorporate more than one, he explains, and the right mix depends on severity, where the plaques are, health history, and how the disease responds over time.
Topical therapies
For mild to moderate psoriasis, a topical psoriasis cream is usually the first step. Options include corticosteroids, vitamin D analogues like calcipotriene, topical retinoids, and calcineurin inhibitors.
Dr. Werschler notes that there are several newer topical treatments, including roflumilast and tapinarof. "These medications may be referred to as 'steroid sparing' because they are cortisone-free and have fewer side effects, especially with prolonged use. Generally, the use of steroid creams is limited to non-facial and non-genital areas of the body."
Many patients rotate between products to balance how well they work with how the skin tolerates them.
Phototherapy
Controlled exposure to ultraviolet light, most often narrowband UVB, can clear widespread mild to moderate plaques. Treatment can happen in a clinic or with a prescribed home unit.
While phototherapy is used less today, it remains a viable option for some patients, although it is not considered a systemic therapy that treats psoriatic arthritis. For fair-skinned individuals, it may increase the risk of skin cancer, especially with prolonged use.
Oral medications
Methotrexate, cyclosporine, and deucravacitinib are used for moderate to severe disease. Each one needs monitoring through regular lab work and follow-up visits.
Apremilast is an oral medication FDA-approved for mild to moderate psoriasis and psoriatic arthritis. Apremilast does not require any specific laboratory monitoring and is generally well tolerated. Some patients may experience gastrointestinal side effects such as nausea and diarrhoea.
A newer oral psoriasis medication, icotrokinra, was recently approved by the FDA. This medication targets a similar part of the immune system as some injections, known as an IL-23 blocker. This medication must be taken every day on an empty stomach and 30 minutes before eating. The most common side effects include headache, nausea, cough, fungal infections, and fatigue.
Injectable biologics
This newer class targets specific immune signals involved in psoriasis and is approved for moderate to severe cases. Biologics have become a mainstay of therapy for many psoriasis patients.
Medicated shampoos
Scalp psoriasis often responds to over-the-counter or prescription shampoos with coal tar, salicylic acid or ketoconazole, sometimes paired with a topical steroid.
Treatment rarely stays the same. As the disease changes, as new therapies come out, and as patients move through different life stages, the plan should change with them.
When Biologics Become the Right Choice
Biologics aren't the starting point for every patient. They're reserved for moderate to severe psoriasis, usually after topical therapy and oral medications haven't delivered enough relief. Instead of broadly suppressing the immune system the way older drugs do, newer biologics target specific immune pathways involved in psoriasis. As a result, they often produce clearer skin with fewer side effects when properly monitored.
Before starting a biologic, patients are screened for active infections, tuberculosis exposure, and any health conditions that could affect safety. Regular follow-up keeps treatment on track, and serious complications are uncommon with proper care.
Choosing among the available biologics is where research experience makes a difference. Having served as a principal investigator on many FDA approved psoriasis clinical trials through Premier Clinical Research in Spokane, Dr. Werschler's work shapes how he weighs efficacy data, how long a response lasts and patient-specific factors when guiding these decisions.
Lifestyle Factors That Make Psoriasis Worse (and Better)
Dr. Werschler points out that there are seven lifestyle factors that consistently affect psoriasis: stress, smoking, alcohol, skin injury, body weight, certain medications, and sun exposure. Daily habits won't replace medical treatment, but they can make a real difference in how often flares happen and how well treatment works.
- Stress is one of the most commonly reported triggers, and stress management techniques can ease flare intensity.
- Smoking and alcohol are both tied to more severe disease and a weaker response to treatment.
- Skin injury can trigger new plaques at the site of cuts, scrapes or sunburn. This pattern is called the Koebner phenomenon.
- Weight plays a role too. Obesity is linked to more severe psoriasis, and losing weight often improves how patients respond to treatment.
- Certain medications can make the disease worse, including beta-blockers, lithium, antimalarials, and some anti-inflammatory drugs. Patients should always tell their dermatologist about every prescription and supplement they take.
- Dry skin fuels itching and scaling. Heavy moisturizers, ointments, or petroleum jelly applied to damp skin after bathing help seal in moisture.
- Sun exposure in small amounts can briefly improve plaques, but sunburn triggers flares. Broad-spectrum SPF 30 or higher on unaffected skin and limited time in peak sun are the safer choice.
Dr. Werschler also notes that because long-term inflammation can raise heart disease risk, patients with moderate to severe psoriasis benefit from heart health screening as part of regular care. Working with both a dermatologist and a primary care provider helps catch related conditions early.
Building a Psoriasis Care Plan That Works
Psoriasis is chronic, but Dr. Werschler says it's far more manageable than it was even a decade ago. The range of available therapies has expanded, and patients who once cycled through limited options now have real choices at every severity level. According to Dr. Werschler, success starts with an accurate diagnosis, an honest look at severity, and a plan built around the patient.
For anyone whose psoriasis hasn't responded to first-line treatments, a visit with a board-certified dermatologist is often the turning point. Beyond clearing skin, the right plan has the power to protect long-term health.
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