As a clinical dermatologist with over a decade of experience in both an academic hospital setting and small, community private practice, I’ve seen hundreds to thousands of psoriasis patients. And although there is no cure for psoriasis, there are some really great therapies—from topicals to diet, light and stress reduction, antibiotics, and systemic immunosuppressives and biologics.
Yet, we’re still struggling. There are flares and rebounds, periods of waxing and waning, and certainly, no therapy fits all.
So, it becomes even more important for us to take the time to slow down and have a real conversation about how we’re using our medications and caring for our skin. With some simple recommendations, we may be able to better optimize topical treatments and enhance outcomes.
1. Wait—don’t pick those scales off!
Although it may be tempting to pick off those white flakes and get your topical medication closer to where it’s needed most, beware—you may be making your psoriasis worse! Heinrich Koebner described this phenomenon, known as the Koebner phenomenon, where skin lesions will appear in the areas of trauma. A few skin conditions exhibit this phenomenon, and psoriasis and vitiligo are two of them. I can’t tell you how many Marines I’ve known who complained of their stubborn shin psoriasis, only to realize their rubbing boots were the culprit.
2. Consider the source of your itchiness
If your psoriasis tends to be itchy and causing you to scratch, then consider the source. Be sure you’ve discussed this symptom with your physician. Sometimes there may be underlying causes of itchiness such as secondary infection or an internal cause. Consider taking an oral antihistamine such as Benadryl at bedtime. At times, your healthcare provider may recommend one that is stronger or consider a different class of medication to help get control of that stubborn itch.
3. Hydrate your skin, then lock in the moisture
If your skin is dry, it will likely be itchy. Be sure to hydrate and moisturize. Soothing baths are great to not only hydrate the skin but reduce stress, a known trigger for many skin rashes.
Try avoiding harsh soaps that may further dry or irritate your compromised skin. Instead, opt for plain, warm water or the addition of colloidal oatmeal, Dead Sea salts or Epsom salts. Pat your skin dry or use your hands to gently wipe off wet skin.
Slather on your favorite moisturizer while your skin is still damp. If your skin is still feeling dry after using a lotion, consider a cream. If your skin is still dry after a cream, consider an oil or ointment. In general, your skin should feel soothed by your emollient. If you experience burning or itching, you may want to reduce fragrance, preservatives, and any other active ingredients to minimize contact allergy or irritation.
4. Descale Gently
Ridding yourself of those messy scales not only feels incredibly satisfying and smooth but also helps to prepare your skin for the real workhorse topical medications, such as corticosteroids. Without descaling, treatment takes longer or may be ineffective, as topicals will remain sitting on top of the dead skin, or in the case of light therapy, end up reflecting off the scaly skin.
Topical keratolytics such as products containing salicylic acid, urea or alpha-hydroxy acids, such as glycolic and lactic acids, help to gently soften and break up dead skin proteins called keratins.
Topical retinoids, such as tazarotene, can also be used to help normalize the revved up skin cycle and shed thickened, dead skin.
As there are several different forms available—liquids, lotions, creams, and ointments—in a variety of strengths, be sure to discuss with your prescriber proper application, removal, and frequency of use. Some can be so powerful, they may be used to remove thickened toenails! And irritation is common, so it’s best to honor those symptoms and treat itchiness and stinging with the use of topical corticosteroids. In fact, combination keratolytic-corticosteroids may be preferred.
Alternatively, or in addition, oil under occlusion can also help to descale gently. I particularly like this method of descaling for the scalp. Kitchen oils such as olive or coconut oils will do just as fine as medical grade mineral and peanut oils. Wear a shower cap or warm, wet head wrap, turban-style, for a half hour or even overnight to facilitate softening and breaking down the dead skin.
Gently, yes GENTLY, use a shampoo massager brush or comb/brush with rounded, smooth bristles to remove the scale without traumatizing the delicate skin below.
This may be a great time to use a medicated shampoo (AKA scalp medication that comes in the form of a shampoo meant to be left on for 5 minutes prior to rinsing)—antifungal, antimicrobial, or tar-based—to further treat your scalp skin and remove the oily residue. (You may then follow with your favorite shampoo and conditioner to treat your hair.) Your scalp skin is now “primed” and ready to receive your topical medication, which may include a corticosteroid.
Please note, you’ll want to use this descaling technique a few days before initiating light therapy as some medications may be UV-blocking.
5. Take a topical steroid holiday
Topical corticosteroids work wonders to relieve itch, redness, and inflammation, but we want them to continue to work when we need them most. Be sure to discuss the application and frequency with your provider.
A little goes a long way! There’s no need to slather it on, although I may advise patients to slather a thick layer of moisturizer on top to occlude it and enhance penetration.
And be sure to understand that it’s important to take a steroid holiday to avoid tolerance or tachyphylaxis. If used over two weeks, I generally recommend taking a few days off, such as the weekend. Be sure to discontinue use once you can close your eyes and feel there is no difference between the affected skin and normal appearing skin. No one wants to trade thickened skin for thinned skin.
With drug advances, we have an ever-increasing number of great therapies, yet sometimes our greatest successes may be found in the details of how we care for our skin—from itch control to bathing and preparing your skin for proper contact and absorption of topical medications and light therapies.
Please spread these simple tips with others who may need some help with their skin. Together, we can optimize first-line topical treatments and facilitate more “good-skin” days.