Psoriasis treatments: overview of systemic medicines

Some people we talked to had tried systemic medicines for psoriasis after trying other treatments first, such as steroid creams. Systemic treatments are prescribed to people who have severe psoriasis covering a big portion of the body and if other treatments have not worked or if they stopped using them because of major side effects. Lisa asked her GP for systemic treatments when she was younger but she was told to try other options first because the medicines can have side effects and risks. Many people had heard that some systemic medicines are expensive to the NHS and saw this as a factor which might affect a doctor’s willingness to prescribe those particular options.

Systemic treatments for psoriasis affect the person’s whole body rather than just the part where topicals, like steroids, are applied. There are two types of systemic medicines which are swallowed as tablets or given as injections and drips:

  • non-biological systemic treatments, such as cyclosporine (also spelt ciclosporin), acitretin and methotrexate, which are usually taken as tablets
  • biological systemic treatments which are injected, sometimes with an injector pen at home, such as adalimumab (e.g. Humira), etanercept (e.g. Enbrel) and ustekinumab (e.g. Stelara). Infliximab is given through a drip in hospital.

Dr McPherson says it’s not possible to always predict who will benefit from each type of systemic treatment or who will get side effects.

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And then you’ve got tablet types of treatments, or injections. The tablet treatments that are kind of licensed and we use regularly for psoriasis, there’s one called methotrexate. Which can be, you know, very effective and- but it does need regular blood tests because it can cause problems with your, your blood counts and you liver. And then you’ve got other tablets as well, which work in completely different ways. And we haven’t yet got a test- so we can’t look at someone and say, Your psoriasis is gonna respond best to this treatment, and your psoriasis is gonna respond best to this treatment. Maybe in the future we’ll be able to do that sort of thing, where we can actually say- you know, take a test and tell them which treatment they’re gonna respond best to. And that’s an area of active research. But at the moment we have lots of different treatments which work in very different ways. And sometimes it’s a case of trial and error.

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Systemic treatments were seen by most people as ‘big’ and ‘serious’ medicines for psoriasis because they knew that they were used to treat other conditions such as cancer (chemotherapy treatment) and in organ transplants. For psoriasis, systemic drugs like methotrexate and cyclosporine are used to reduce inflammation. Steven’s keen to avoid systemic medicines ‘for as long as possible’ and prefers trying other treatments (e.g. steroids, dithranol, phototherapy). Systemic treatments can be effective but can have serious side effects. Both cyclosporine and methotrexate can cause damage to organs (such as the kidneys and liver) and bone marrow, which is why people need regular blood tests to check for side effects. Methotrexate can cause fetal anomalies (birth defects) for both women who become/are pregnant and men who impregnate women whilst taking the treatment. Acitretin is not usually prescribed to women because it can continue to cause fetal anomalies up to three years after treatment has ended.

Lisa talks about having blood tests whilst taking systemic medicines for psoriasis.

Age at interview 20

Gender Female

Age at diagnosis 11

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I think it’s because they can cause complications. I know there’s-, the-, all of them that I’ve been on, they can cause something with your liver, they can cause like blood count issues blood pressure issues. So they don’t really like giving them to children.

Do you have any sort of check-ups to keep an eye on it?

Yeah, at the beginning you have a lot of blood tests to make sure that your blood count and your kidney functions and things like that are working in order. And then as you get- , as you become on them more you don’t have to have the blood tests as regularly, but you still have to just in case especially with the methotrexate that I’m on since it was used initially for cancer, I have to make sure that I don’t take medication like ibuprofen that can interact with it. I think it’s ibuprofen, but I can’t take things like will interact with it and I have to keep a little book so that they know like my blood pressure or my white blood counts and things like that.

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Hannah will stop systemic psoriasis treatment when she’s planning to have children.

Age at interview 24

Gender Female

Age at diagnosis 16

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I’m pretty sure all the medication I’ve been on from methotrexate, cyclosporine and now the biologics, you can’t get pregnant on them. So when you get to the stage where you’re thinking about having children you have to come off the drug and there’s certain amount of time for each one that you have to be off it and I think for Stelara they said about a year or half a year or something so, you know, when it gets to that stage of my life I’ll have to think quite far ahead about coming off it and giving myself enough time to get it out of my system. And I think even then I’ll, I will sort of still worry to an extent that, you know, has it affected my body in some kind of way.

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Hannah still needs blood tests but has now she’s on Stelara (ustekinumab injections) than when she took methotrexate.

Age at interview 24

Gender Female

Age at diagnosis 16

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The only problem is also, I, it’s hard, blood tests it’s hard to get blood out often with me. So I find that like some of the more experienced nurses can do it, whereas other times I do often feel like a pin cushion cos like they’re having to do it so many times. With Stelara, it’s not so bad because I don’t have blood tests that regularly only three, every three months. But with methotrexate I had to have a blood test every week. So before the medication I’d have to have a blood test. So that was a lot harder.

And did you have to go to your GP or up to a dermatologist?

I used to go to a GP just because it was easiest. And then they would send it over.

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