Oral systemic medications

Cyclosporine

This is another drug that slows skin growth by preventing some of the activity of the immune system, and it is effective for the treatment of severe psoriasis in patients for whom conventional therapy is ineffective or inappropriate. Cyclosporine is taken orally. Patients may experience abnormal sensation on the skin, gingival overgrowth (gum enlargement), gastrointestinal disorder, flu-like symptoms and upper respiratory infections. Cyclosporine also requires regular blood testing.

Methotrexate

A drug that slows down the rapid growth of skin cells and suppresses the immune system by interfering with DNA synthesis, repair, and replication of cells. Methotrexate is indicated for treatment of severe, disabling psoriasis and psoriatic arthritis which has not responded adequately to other therapies. Methotrexate is taken orally or by injection into the muscle or under the skin. Common side effects of metrotrexate therapy include leukopenia (decreased white blood cells), abdominal distress, malaise (general discomfort), flu-like symptoms, and decreased resistance to infection, and requires regular blood testing.

Oral retinoids (acitretin)

Derived from vitamin A, these drugs regulate how skin cells grow and are shed from the surface of the skin. Oral retinoids such as acitretin are authorized for the treatment of patients with severe psoriasis, including pustular and erythrodermic forms, who are unresponsive or intolerant to standard treatment. These drugs are somewhat effective when used on their own; but can improve the response to PUVA and UVB. Oral retinoids can increase blood lipids and birth defects. Other common side effects include skin peeling, hair loss and dryness of facial features (lips, eyes, mouth). These drugs require regular blood testing.

Injectable systemic medications

Biologics

Biologic response modifiers (commonly referred to as 'biologics') are a class of medications that have been developed to target specific actions in the immune system. Research has shown plaque psoriasis develops when, in addition to other factors, certain immune system cells are triggered accidentally, and send signals to the skin cells telling them to mature and multiply at an abnormally fast rate. The body has no way to shed the skin cells fast enough, and they accumulate on the surface of the skin. The result is red, raised, scaly or flaky patches or "plaques" of skin. Some of the immune cells that are believed to play a role in the mediation of plaque psoriasis are T-cells (or white blood cells) and the chemical messengers released by T-cells.

Biologic medications have been shown to be effective for the treatment of moderate to severe plaque psoriasis. Some work by interfering with certain T-cell activities, while others work by blocking the release of certain chemical messengers. Each works a little differently to prevent immune system cells from communicating with skin cells. Because these types of biologics suppress the immune system, they may reduce your ability to fight infection. If you have recurring infections, you should discuss other treatment options with your doctor.

Adalimumab

Adalimumab blocks the chemical messenger TNF-alpha, thus interrupting the inflammatory cycle of psoriasis. Adalimumab is a prescription biologic that is authorized for the treatment of adult patients with chronic moderate to severe psoriasis who are candidates for systemic therapy. Adalimumab is also authorized for the reduction of signs and symptoms, inhibiting structural damage progression and improving physical function of moderately to severely active arthritis in adult patients with psoriatic arthritis (PsA). For patients with chronic moderate plaque psoriasis, adalimumab should be used after phototherapy has been shown to be ineffective or inappropriate. This drug is injected under the skin once every other week. Common and more serious side effects include injection site reactions, tiredness, nausea, upper respiratory infections, invasive fungal infections, more serious infections and nervous system disorder, and may increase the risk of certain types of malignancies.

Adalimumab has the potential to reactivate tuberculosis, and therefore a skin test or chest X-ray is required to check for tuberculosis before beginning treatment with this medication. Adalimumab may not be appropriate for people with serious infections or a history of recurring infections.

Alefacept

Alefacept blocks the activation of certain immune cells called T cells (a type of white blood cell). In psoriasis, once T cells are mistakenly activated, they can trigger inflammation and fuel the development of psoriasis lesions. By blocking T cell activation, alefacept interrupts the cycle of psoriasis . Alefacept is authorized for use in adults with moderate-to-severe plaque psoriasis who are candidates for phototherapy or other systemic treatments. This drug is injected into the muscle once per week for up to 12 weeks. Common and more serious side effects include accidental injury, dizziness, nausea, itchiness, flu-like symptoms, sore throat, infection, and a condition where there is a low level of lymphocytes (a type of white blood cell) in the blood. Blood tests are required every couple of weeks to monitor immune cell counts.

Etanercept

Etanercept blocks a chemical messenger in the immune system, called tumour necrosis factor-alpha (TNF-alpha). There is too much TNF-alpha in the skin of patients with psoriasis and the joints of people with certain types of arthritis. Etanercept is authorized for the treatment of adults with moderate-to-severe plaque psoriasis who are candidates for phototherapy or other systemic treatments. Etanercept is also authorized for the reduction of signs and symptoms, inhibiting structural damage progression and improving physical function of moderately to severely active arthritis in adult patients with psoriatic arthritis (PsA). This drug is injected under the skin once or twice a week. Common and more serious side effects include injection site reaction, tiredness, nausea, upper respiratory infections, invasive fungal infections, more serious infections and nervous system disorder, and may increase the risk of certain types of malignancies.

Etanercept has the potential to reactivate tuberculosis, and therefore a skin test or chest X-ray is required to check for tuberculosis before beginning treatment with this medication. Etanercept may not be appropriate for people with serious infections or a history of recurring infections.

Infliximab

Infliximab also blocks the chemical messenger, TNF-alpha, thus interrupting the inflammatory cycle of psoriasis. Infliximab is prescribed for people with chronic moderate-to-severe plaque psoriasis, after phototheraphy has been shown to be ineffective or inappropriate, and is authorized for the reduction of signs and symptoms, induction of major clinical response, and inhibition of the progression of structural damage of active arthritis, and improvement in physical function in patients with psoriatic arthritis (PsA). This drug is given by intravenous infusion, at scheduled intervals. Common and more serious side effects include infusion site reactions, tiredness, nausea, upper respiratory infections, invasive fungal infections, more serious infections and nervous system disorder, and may increase the risk of certain types of malignancies.

Infliximab also has the potential to reactivate tuberculosis, and therefore a skin test or chest X-ray is required to check for tuberculosis before beginning treatment with this medication. Infliximab may not be appropriate for people with serious infections or a history of recurring infections.

Ustekinumab

Ustekinumab blocks the action of two proteins, interleukin 12 (IL-12) and interleukin 23 (IL-23) and it is believed to interrupt the inflammatory cycle of psoriasis. Ustekinumab is a prescription biologic that is authorized for the treatment of adult patients with chronic moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. This drug is injected under the skin. Your doctor will determine the right dose for you and how often you should receive it. Side effects include inflammation of the nose and pharynx, upper respiratory infections, headache, rash and other serious infections, and may increase the risk of certain malignancies. Patients are tested for TB prior to starting ustekinumab. Ustekinumab may not be appropriate for people with serious infections or a history of recurring infections.

Biologic	How it works	What it is prescribed for	How it is given	Special monitoring
Adalimumab	Blocks the chemical messenger, TNF	Chronic moderate to severe psoriasis & psoriatic arthritis	Injection under the skin every other week	TB test required before starting medication
Alefacept	Blocks activation of T cells	Moderate to severe plaque psoriasis	Injection into muscle once a week	Blood tests required every two weeks
Etanercept	Blocks the chemical messenger, TNF	Moderate to severe plaque psoriasis & psoriatic arthritis	Injection under the skin once or twice a week	TB test required before starting medication
Infliximab	Blocks the chemical messenger, TNF	Chronic moderate to severe plaque psoriasis & psoriatic arthritis	Intravenous infusion at scheduled intervals	TB test required before starting medication
Ustekinumab	Blocks proteins, interleukin 12 (IL-12) and interleukin 23 (IL-23)	Chronic moderate to severe plaque psoriasis	Injection under the skin at a schedule determined by your doctor	TB test required before starting medication

All medicines have side effects and should be used as directed and under the supervision of a healthcare professional.

Make sure your doctor is aware of any other medications you may be taking.

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