What Pharmacists Need to Know About Psoriasis Medications

Pharmacists can play an integral role in managing patients with psoriasis through medication therapies and lifestyle modifications. 

Psoriasis is a common chronic autoimmune disease that affects the skin, causing raised, red, scaly patches. Complications may include psoriatic arthritis, metabolic disorders, and cardiovascular disease. 

Psoriasis Treatment Options and Counseling Pearls

Treatment for psoriasis can be broken down into 3 categories: topical, phototherapy, and systemic medications. Phototherapy is a prescription treatment usually performed by a dermatologist that involves exposing the skin to controlled amounts of ultraviolet light. Most patients with mild-to-moderate psoriasis can have their symptoms controlled with topical medications or phototherapy, while biologics should be reserved for individuals with moderate-to-severe psoriasis.¹ Topical products may be available OTC or by prescription. Salicylic acid products are available OTC and work as a scale lifter to help soften and remove scales and plaques. Coal tar is found in OTC shampoos, creams, and oils, but it can irritate the skin and should be avoided in women who are pregnant or breast-feeding. Moisturizers with an ointment base can be more effective than creams or lotions and should be applied right after a bath or shower to lock in the moisture. Prescription topical non-steroid options include vitamin D analogues such as calcipotriene (Dovonex) and calcitriol (Vectical), and these products may cause skin irritation.

Topical corticosteroids are the most common treatment option for mild-to-moderate psoriasis and may be combined with phototherapy for more severe cases. It is important for patients to apply a small amount on the affected areas. Pharmacists should recommend short-term use of corticosteroids since they can cause thinning of the skin and may stop working overtime. Systemic medications are used to treat moderate-to-severe psoriasis and are an option for patients that do not respond to topical drugs or phototherapy. Acitretin (Soriatane) is an oral retinoid taken once per day with food. Acitretin can cause severe birth defects so it’s important to counsel that women of childbearing potential must have 2 negative pregnancy tests before starting the medication, and use 2 effective forms of birth control at least 1 month before beginning therapy, while on the drug, and for 3 years after stopping. Cyclosporine is taken orally daily for up to 2 years and may increase the risk of developing infections, kidney problems, hypertension, and skin cancer. Methotrexate is available orally and as a subcutaneous injection and may cause stomach pain, appetite loss, and fatigue as well as serious adverse effects including liver damage and low blood counts. Apremilast (Otezla) is taken orally twice per day, and adverse effects include diarrhea, nausea, and vomiting. Tofacitinib (Xeljanz) is taken orally once or twice daily, and adverse effects include upper respiratory infections, headache, diarrhea, and an increased risk of serious infections.²

Biologics target specific parts of the immune system and are taken by injection or intravenous infusion. Medications include certolizumab pegol (Cimzia), secukinumab (Cosentyx), etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade), and brodalumab (Siliq), among others. Biologics can increase the risk of infection and tuberculosis screening is required prior to starting therapy. All inactivated vaccines can be given with biologics; however, biologics may need to be stopped prior to and after administering live vaccines.

References:

• National Psoriasis Foundation. About Psoriasis. https://www.psoriasis.org/about-psoriasis.

• Menter A, Strober BE, Kaplan DH. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. Journal of the American Academy of Dermatology. 2019. Doi:  https://doi.org/10.1016/j.jaad.2018.11.057.

• National Psoriasis Foundation. Treatment Comparison [chart]. June 2019.

• .

• FDA. Biosimilar Product Information. FDA’s website. November 11, 2019. https://www.fda.gov/drugs/biosimilars/biosimilar-product-information.

• Statement from Sarah Yim, MD, acting director of the Office of Therapeutic Biologics and Biosimilars in the FDA’s Center for Drug Evaluation and Research, on FDA’s continued progress facilitating competition in the biologic marketplace with approval of 25^th biosimilar [FDA statement]. FDA’s website. November 15, 2019. https://www.fda.gov/news-events/press-announcements/statement-sarah-yim-md-acting-director-office-therapeutic-biologics-and-biosimilars-fdas-center-drug.

• Bimekizumab Phase 3 Psoriasis Study Meets All Endpoints, Achieving Significantly Greater Efficacy Versus Placebo and Ustekinumab [news release]. UCB’s website. October 17, 2019. https://www.ucb.com/stories-media/Press-Releases/article/Bimekizumab-Phase-3-Psoriasis-Study-Meets-All-Endpoints-Achieving-Significantly-Greater-Efficacy-Versus-Placebo-and-Ustekinumab.