Moderate to Severe Psoriasis: Biologic

Biologic drugs, or "biologics," are given by injection or intravenous (IV) infusion. A biologic is
a protein-based drug derived from living cells cultured in a laboratory. While biologics have
been used to treat disease for more than 100 years, the advent of modern day molecular
biologic techniques has accelerated their use in modern day medicine tremendously in the
last decade.
Different from the traditional systemic drugs that impact the entire immune system, biologics
target specific parts of the immune system. The biologics used to treat psoriatic diseases
act by blocking the action of a specific type of immune cell called a T cell, or by blocking
proteins in the immune system, such as tumor necrosis factor-alpha (TNF-alpha) or
interleukins 12 and 23. These cells and proteins all play a major role in developing psoriasis
and psoriatic arthritis.
Biosimilar substitution
The National Psoriasis Foundation Medical Board has issued a statement on biosimilar
substitution. Read the statement »

Tumor necrosis factor-alpha (TNF-alpha) blockers
Enbrel (etanercept), Humira (adalimumab), Remicade (infliximab) and Simponi
(golimumab) are drugs that block TNF-alpha. TNF-alpha is a cytokine, or a protein, that
signals the body to create inflammation. In psoriasis and psoriatic arthritis, there is excess
production of TNF-alpha in the skin or joints. That leads to the rapid growth of skin cells
and/or damage to joint tissue. Blocking the TNF-alpha production helps stop the
inflammatory cycle of psoriatic diseases.
Interleukin 12/23
Stelara (ustekinumab) works by selectively targeting the proteins, or cytokines, interleukin-
12 (IL-12) and interleukin 23 (IL-23). Interleukins-12/23 are associated with psoriasis
How are they used?
The biologics are taken by injection or by IV infusion. Enbrel, Humira and Simponi are
injected in the legs, abdomen or arms, typically by the individual with psoriasis or a family
member. Stelara is administered as a subcutaneous injection by a health care provider.
Remicade is given through IV infusion in a doctor’s office or infusion center. Biologics are
prescribed for individuals with moderate to severe cases of plaque psoriasis and psoriatic
arthritis. They are a viable option for those who have not responded to or have experienced
harmful side effects from other treatments. The TNF-alpha blockers help reduce the
progression of joint damage in psoriatic arthritis.
Do not take biologics if:
 Your immune system is significantly compromised;
 You have an active infection.
Screening for tuberculosis (TB) or other infectious diseases is required before starting
treatment with Enbrel, Humira, Remicade, Simponi and Stelara.
What are the risks?
Anyone considering taking a biologic drug should talk with his or her doctor about the short-
and long-term side effects and risks. It is important to weigh the risks against the benefits of
using the drugs.
Biologics can increase the risk of infection. Individuals who develop any sign of an infection
such as a fever, cough or flu-like symptoms or have any cuts or open sores should contact
their doctor right away.
The impact of biologics on developing fetuses or nursing infants is not known. Biologics
should only be prescribed to pregnant or nursing women if there is a clear medical need.
Common side effects for biologics include:
 Respiratory infections
 Flu-like symptoms
 Injection site reactions
These side effects are generally mild and in most cases do not cause individuals to stop
taking the medication.
Rare side effects for biologics include:
 Serious nervous system disorders, such as multiple sclerosis, seizures, or
inflammation of the nerves of the eyes;
 Blood disorders;
 Certain types of cancer.
Call your doctor if you are experiencing any side effects with biologic drugs. For specific
side effect information, download the individual product fact sheet.
Using biologics with other psoriasis treatments
All the current biologics can be used with other treatments such as phototherapy or topicals,
though using phototherapy along with Remicade may increase skin cancer risk.
Enbrel, Humira and Remicade are shown to be safe and effective when taken with
methotrexate. Talk to your doctor about whether using any other treatments with a biologic
is right for you.
Traditional Systemic Medications
Systemic medications are prescription drugs that work throughout the body. They are
usually used for individuals with moderate to severe psoriasis and psoriatic arthritis.
Systemic medications are also used in those who are not responsive or are unable to
take topical medications or UV light therapy.

Systemic psoriasis drugs are taken by mouth in liquid or pill form or given by injection.
Systemics have been used for more than 10 years.

Learn more about traditional systemics
 Acitretin (Soriatane)
 Cyclosporine
 Methotrexate
 Off-label systemics
Phototherapy or light therapy, involves exposing the skin to ultraviolet light
on a regular basis and under medical supervision. Treatments are done in a doctor's office
or psoriasis clinic or at home with phototherapy unit. The key to success with light therapy is

National Psoriasis Foundation does not support the use of indoor tanning beds as a
substitute for phototherapy performed with a prescription and under a doctor's supervision.
Read more on the Psoriasis Foundation position on indoor tanning beds »

Ultraviolet light B (UVB)/Ultraviolet light A (UVA) Treatments
UVB phototherapy
Present in natural sunlight, UVB is an effective treatment for psoriasis. UVB penetrates the
skin and slows the growth of affected skin cells. Treatment involves exposing the skin to an
artificial UVB light source for a set length of time on a regular schedule. This treatment is
administered in a medical setting or at home.
There are two types of UVB treatment, broad band and narrow band. The major difference
between them is that narrow band UVB light bulbs release a smaller range of ultraviolet
light. Narrow-band UVB is similar to broad-band UVB in many ways. Several studies
indicate that narrow-band UVB clears psoriasis faster and produces longer remissions than
broad-band UVB. It also may be effective with fewer treatments per week than broad-band
During UVB treatment, your psoriasis may worsen temporarily before improving. The skin
may redden and itch from exposure to the UVB light. To avoid further irritation, the amount
of UVB administered may need to be reduced. Occasionally, temporary flares occur with
low-level doses of UVB. These reactions tend to resolve with continued treatment.
UVB can be combined with other topical and/or systemic agents to enhance efficacy, but
some of these may increase photosensitivity and burning, or shorten remission. Combining
UVB with systemic therapies may increase efficacy dramatically and allow for lower doses
of the systemic medication to be used.
Home UVB phototherapy
Treating psoriasis with a UVB light unit at home is an economical and convenient choice for
many people. Like phototherapy in a clinic, it requires a consistent treatment schedule.
Individuals are treated initially at a medical facility and then begin using a light unit at home.
It is critical when doing phototherapy at home to follow a doctor's instructions and continue
with regular check-ups. Home phototherapy is a medical treatment that requires monitoring
by a health care professional.
All phototherapy treatments, including purchase of equipment for home use, require a
prescription. Some insurance companies will cover the cost of home UVB equipment.
Vendors of home phototherapy equipment often will assist you in working with your
insurance company to purchase a unit.
Although both UVB and ultraviolet light A (UVA) are found in sunlight, UVB works best for
psoriasis. UVB from the sun works the same way as UVB in phototherapy treatments.
Short, multiple exposures to sunlight are recommended. Start with five to 10 minutes of
noontime sun daily. Gradually increase exposure time by 30 seconds if the skin tolerates it.
To get the most from the sun, all affected areas should receive equal and adequate
exposure. Remember to wear sunscreen on areas of your skin unaffected by psoriasis.
Avoid overexposure and sunburn. It can take several weeks to see improvement. Have your
doctor check you regularly for sun damage.
Some topical medications can increase the risk of sunburn. These include tazarotene, coal
tar, Elidel (pimecrolimus) and Protopic (tacrolimus). Individuals using these products should
talk with a doctor before going in the sun.
People who are using PUVA or other forms of light therapy should limit or avoid exposure to
natural sunlight unless directed by a doctor.

Psoralen + UVA (PUVA)
Like UVB, ultraviolet light A (UVA) is present in sunlight. Unlike UVB, UVA is relatively
ineffective unless used with a light-sensitizing medication psoralen, which is administered
topically or orally. This process, called PUVA, slows down excessive skin cell growth and
can clear psoriasis symptoms for varying periods of time. Stable plaque psoriasis, guttate
psoriasis, and psoriasis of the palms and soles are most responsive to PUVA treatment.
The most common short-term side effects of PUVA are nausea, itching and redness of the
skin. Drinking milk or ginger ale, taking ginger supplements or eating while taking oral
psoralen may prevent nausea. Antihistamines, baths with colloidal oatmeal products or
application of topical products with capsaicin may help relieve itching. Swelling of the legs
from standing during PUVA treatment may be relieved by wearing support hose.

Laser Treatments
Excimer laser
The excimer laser—recently approved by the Food and Drug Administration (FDA) for
treating chronic, localized psoriasis plaques—emits a high-intensity beam of ultraviolet light
B (UVB).
The excimer laser can target select areas of the skin affected by mild to moderate psoriasis.
Individual response to the treatment varies. It can take an average of four to 10 sessions to
see results, depending on the particular case of psoriasis. It is recommended that patients
receive two treatments per week, with a minimum of 48 hours between treatments.
There is not yet enough long-term data to indicate how long the improvement will last
following a course of laser therapy.
Pulsed dye laser
Like the excimer laser, the pulsed dye laser is approved for treating chronic, localized
plaques. Using a dye and different wavelength of light than the excimer laser or other UVB-
based treatments, pulsed dye lasers destroy the tiny blood vessels that contribute to the
formation of psoriasis lesions.
Treatment consists of 15- to 30-minute sessions every three weeks. For patients who
respond, it normally takes about four to six sessions to clear the target lesion.
The most common side effect is bruising after treatment, for up to 10 days. There is a small
risk of scarring.

Tanning beds
Some people visit tanning salons as an alternative to natural sunlight. Tanning beds in
commercial salons emit mostly UVA light, not UVB. The beneficial effect for psoriasis is
attributed primarily to UVB light. National Psoriasis Foundation does not support the use of
indoor tanning beds as a substitute for phototherapy performed with a prescription and
under a doctor's supervision. Read more on the Psoriasis Foundation position on indoor
tanning beds »
The American Academy of Dermatology, the FDA and the Centers for Disease Control
and Prevention all discourage the use of tanning beds and sun lamps. The ultraviolet
radiation from these devices can damage the skin, cause premature aging and increase the
risk of skin cancer.
Topical Treatments
Topical treatments—medications applied to the skin—are usually the first line of defense in
treating psoriasis. Topicals slow down or normalize excessive cell reproduction and reduce
psoriasis inflammation.
There are several effective topical treatments for psoriasis. While many can be purchased
over the counter (OTC), others are available by prescription only.
Corticosteroids, or just "steroids," are the most frequently used treatment for psoriasis. They
are referred to as anti-inflammatory agents, because they reduce the swelling and redness
of lesions. Anthralin, synthetic vitamin D3, and vitamin A are also used in prescription
topical treatments to control psoriasis lesions.
OTC topicals come in many different forms. Two active ingredients, salicylic acid and coal
tar, are approved by the FDA for the treatment of psoriasis. There are other products that
contain substances such as aloe vera, jojoba, zinc pyrithione and capsaicin, which are used
to moisturize, soothe, remove scale or relieve itching.
Complementary and Alternative Therapies
Many patients today with chronic conditions, including psoriasis and psoriatic arthritis, have
an interest in complementary and alternative therapies—these focus more on preventative
care and pain management.
Surveys for the National Center for Complementary and Alternative Medicine (NCCAM) and
National Center for Health Statistics (part of the Center for Disease Control and Prevention)
show more than a third of Americans (36 percent) use complementary and alternative
therapies. These therapies include diet, herbs and supplements, mind/body therapies such
as aromatherapy, yoga and meditation, physical therapies, exercise and the ancient arts of
acupuncture and tai chi.
Much of the evidence supporting complementary and alternative therapies for psoriasis and
psoriatic arthritis is anecdotal. Increasingly, researchers have studied complementary and
alternative therapies particularly in looking at drug interactions, dietary outcomes and
safety. Most complementary and alternative therapies are safe. However, some can
interfere with your treatments prescribed by your doctor.
Always talk to your doctor or consult with a licensed health care professional before adding
any complementary and alternative treatments to your treatment plan for psoriasis and
psoriatic arthritis.