What if your Psoriasis treatment is no longer working?

So say, you have finally found a good treatment regimen that is keeping your psoriasis under control. Then, maybe suddenly, or perhaps slowly over time, you find that the treatment is not working as well any more. Nothing can be more frustrating than a relapse after you have worked so hard to keep your skin under control!

Why is this happening to you? If your psoriasis treatment is no longer working, there are several causes to consider:

●Your body has become resistant to your treatment. 
Sometimes your body can become “immune” to your treatments. This can happen in two different ways:

1. With systemic biologic medications, sometimes your body can make antibodies to the medicine. If you develop antibodies to your medication it is not usually harmful, but it may mean that your medicine does not work as well as it once did. A large review study in 2014 showed that this can occur in up to 45% of patients on biologic medications. If this happens, your provider may change your medicine or add an additional treatment. We now understand that antibodies to medication are more likely to develop if you skip a dose or have a break in your treatment. Make sure you are using your medicine as prescribed. If you develop any side effects and are tempted to stop treatment, let your provider know right away!

2. With topical steroids, some people believe in a phenomenon called tachyphylaxis or tolerance. Now this isn’t as scary as it sounds! The thought is that if you apply a topical steroid to the same area of your skin every single day, it stops working because your skin “gets used to it.” This is one of the reasons why many providers will recommend a scheduled break from applying the steroid. As an example, a regimen may be to apply the cream Monday through Friday and “take the weekends off” from applying the medicine. Alternatively, some providers will recommend that you apply the medicine daily for two weeks and then take a week off.

Another technique is to add a different psoriasis treatment, such as phototherapy, to help your skin improve faster and with less steroid. Not everyone agrees that applying a steroid to the skin causes tolerance and research has not been conclusive. Some patients, however, swear it’s true! Make sure you are clear on the medication instructions your provider is giving to you.

● Your treatment needs more time to work. 
Some treatments, such as topical steroids, get to work very quickly while others, such as some systemic biologic medications, can take months to work.  If you are using phototherapy, you will have to build up the dose gradually to achieve a maintenance dose that keeps your skin clear.  As the optimal dose changes several times, it’s helpful to have guidance when needed. Make sure you are communicating with your provider about how long you should expect to wait for a treatment to be effective. He or she may recommend adding a temporary treatment while you are waiting for your prescription to work.

● Your psoriasis may not be psoriasis.
While psoriasis is common, there are many other mimickers such as eczema, contact dermatitis and infection. Your Dermatology provider can help determine if your skin symptoms are actually psoriasis or if something else is going on. While making your own diagnosis on the internet may be tempting, you may be hurting yourself in the long run!

● Your skin is infected.
Does your skin have a honey crust or is it oozing? A skin infection may be halting your progress. We talked about this more in depth in this post, but in short, a skin infection can slow resolution of your psoriasis lesions. Even worse, some psoriasis medications can feed an infection so it’s important to get a diagnosis.

● You haven’t kept up with your treatment.
Let’s get real for a minute. Have you been faithfully applying your psoriasis medicine? Having psoriasis sometimes can be a lot work, we admit it!  It’s perfectly normal to occasionally get behind in your medicine applications. If this happens, it’s important to get back on your regimen as soon as you can. Remember, it may take some time for your skin to clear back to how it looked previously. As we talked about above, if you are on a systemic medication, taking breaks in your medication is not a good idea unless it was prescribed by your doctor. So get honest with yourself.  If your treatment regimen doesn’t fit well with your lifestyle, let your provider know. We won’t be offended! There are many options for treating psoriasis and we can customize a regimen that’s best for you. Even phototherapy can now be performed at home at your convenience.

● Stress and everything else!
Finally, what else is going on in your life? Have you been under extra stress recently?  Multiple studies have shown that stress can trigger psoriasis flares. Sometimes finding effective ways to manage stress can make a world of difference in how your skin feels. Have you also considered stress to the skin, such as a sunburn? Remember, while the correct amount of UV light can help your psoriasis, too much sunlight can cause a sunburn and lead to a psoriasis flare. Lastly, let your provider know if you have had any changes in your weight. if you are on a systemic medication and you have gained weight, your dose may not be high enough. Often the fix is just a little dose adjustment.So, if your once-perfect psoriasis regimen is no longer working well, schedule a visit with your provider and discuss if one of the above factors is playing a role in your relapse. Before you go, consider keeping a psoriasis journal. In your journal, document your symptoms and when you used your medicines.  If you are using phototherapy, make sure you are keeping track of your dose, and how frequent you are using it. Also take note if you have been under unusual stress or haven’t slept as well.

So, if your once-perfect psoriasis regimen is no longer working well, schedule a visit with your provider and discuss if one of the above factors is playing a role in your relapse. Before you go, consider keeping a psoriasis journal. In your journal, document your symptoms and when you used your medicines.  If you are using phototherapy, make sure you are keeping track of your dose, and how frequent you are using it. Also take note if you have been under unusual stress or haven’t slept as well.

If your psoriasis treatment isn’t working as well as it once did, don’t despair! Let your provider know and together, you can regroup and regain control of your skin.

References:
  1. Hsu L, Snodgrass BT, Armstrong AW. Antidrug antibodies in psoriasis: a systematic review. Br J Dermatol. 2014 Feb;170(2):261-73.
  2. Bartelds GM, Krieckaert CL, Nurmohamed MT, et al. Development of antidrug antibodies against adalimumab and association with disease activity and treatment failure during long-term follow-up. JAMA. 2011;305(14):1460-1468.
  3. Miller JJ, Roling D, Margolis D, Guzzo C. Failure to demonstrate therapeutic tachyphylaxis to topically applied steroids in patients with psoriasis. J Am Acad Dermatol. 1999 Oct;41(4):546-9.
  4. Czarnowicki T, Linkner RV, Suárez-Fariñas M, Ingber A, Lebwohl M. An investigator-initiated, double-blind, vehicle-controlled pilot study: assessment for tachyphylaxis to topically occluded halobetasol 0.05% ointment in the treatment of psoriasis. J Am Acad Dermatol. 2014 Nov;71(5):954-959.e1.
  5. Farber EM, Nall L. Psoriasis: a stress-related disease. Cutis. 1993 May;51(5):322-6.
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