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Psoriasis is a disease that occurs due to immune system dysregulation and takes time and patience to treat. It’s a persistent little bugger that loves to throw curveballs weeks, months, or years into successful treatment.

Therapies that worked in the past may stop being effective (#rude), or you may find you need supplemental medications to get the same results. But fret not. If your current treatment stops working, you’re not destined to a life of untreatable scaliness. You’ve got many options.

Drug resistance

Much like coping with your roommate’s taste in Celtic trance music, your body may get used to topical treatments and develop a tolerance to them (often referred to as tachyphylaxis).

Sometimes the body creates antibodies to fight medications, confusing them for invaders that might harm the body (like bacteria, viruses, or hidden anchovies in your food). If this happens, it’s probably time to switch to alternative treatments.

Drug resistance is most common with biologics — protein-based drugs that come from living cells manufactured in a laboratory.

If your doctor suspects you’ve become resistant, they may switch you to another biologic, or maybe supplement it with a drug called methotrexate (we’ll get to that later).

Historically, doctors used to think you could also develop tachyphylaxis to topical steroids (a typical medication used in treating psoriasis), but there’s no strong evidence to support that notion. As always, speak to your doctor about your options.

Misdiagnosis

Because psoriasis symptoms may appear similar to other skin conditions, it’s possible that your initial psoriasis diagnosis was incorrect.

Eczema, contact dermatitis, or (rarely) mycosis fungoides could all be the cause of your symptoms. So, if your psoriasis treatment stops working, ask your doctor if it could be something else.

Missed doses

Life’s busy and you may forget to take or apply your medication every once in a while. Missing doses may be harmless for some medications, but others only work when taken consistently.

If you’re prone to forgetfulness (this is a judgement-free zone, friends), set up reminders in your phone or calendar. If the issue is financial, look into drug discount programs or more budget-friendly treatments with your doctor.

Stress — that old chestnut

Work deadlines coming up? Relationship woes getting you down? Are you aware of “the news”? Stress can be a major instigator of psoriasis flare-ups, even canceling out the positive effects of treatment.

If you find that you’re more tense than usual, look for ways to manage your stress (such as meditation and/or exercise). It might have a bigger impact on your skin than you realize.

You may need to up the self-care

Losing weight, being active, eating nutritious food, and managing stress can all have big, positive impacts on your psoriasis. If you could use a boost in any of these areas, there’s no time like the present to start implementing healthy changes into your daily life.

Topical treatments

Topical treatments work best on mild to moderate psoriasis. Topical corticosteroids and topical calcineurin inhibitors are commonly used, depending on the area of the body treated. When used alone or alongside vitamin D, they can be quite effective.

However, stronger topical steroids can cause thinning of the skin, among other side effects like stretch marks, so you don’t want to be on them too long, especially when using on thin-skinned areas like groin, body folds, or the face.

Non-steroidal topical treatments

There are many non-steroidal treatments on the market, including topical retinoids, coal tar, vitamin D analogues, and prescription treatments.

Unfortunately, these are all capable of becoming less potent or successful in treating symptoms over time, and there are side effects to take into consideration, as well.

Topical retinoids

Topical retinoids are derived from vitamin A. They help treat psoriasis symptoms by reducing skin cell turnover and reducing inflammation.

Just like your beloved retinol, vitamin A in retinoids can make the skin incredibly sensitive to light — so if you’re using it, make sure to apply UV-blocking sunscreen or protective clothing before leaving the house.

Coal tars

Coal tar is the OG remedy for psoriasis, and has been considered a highly effective treatment for the last 80 years. But are you getting the maximum benefits?

Combined with UV therapy, results are even better, especially with:

  • scalp psoriasis
  • palmoplantar psoriasis
  • localized, chronic plaque psoriasis

Downsides? Tar smells like… well, tar. And it stains easily, so you can’t put it on and then get dressed for the day, or apply it before bed and then get into your nice, clean sheets. It’s also not recommended for women who are pregnant or breastfeeding.

Vitamin D analogues

Vitamin D analogues are used to slow down the growth of plaques. Common prescription options include:

  • Calcipotriene
  • Calcitriol

Anthralin

Anthralin helps to slow down skin cell growth (which is on turbo-mode for people with psoriasis) and can smooth the skin by removing scales. But it can cause skin irritation and, as with tar soap, it stains easily.

Calcineurin inhibitors

Topical calcineurin inhibitors (such as tacrolimus or pimecrolimus) are used off-label for psoriasis and can reduce inflammation and psoriasis plaques by targeting the immune system.

There exists a black box warning for these medications regarding the increased risk for lymphoma on the skin when used long-term, however, a causal relationship has not been firmly established.

Salicylic acid

Salicylic acid can reduce scaling and help exfoliate dead skin cells. It’s often used simultaneously with other topical medications, and can be found in medicated shampoos and solutions to remedy scalp psoriasis.

Salicylic acid is also commonly found in skin care products formulated for acne-prone skin, and is available both over-the-counter (OTC) and by prescription.

Phototherapy

Phototherapy can be successful in treating psoriasis when used on a consistent basis. Options include:

  • natural sunlight
  • narrowband Ultraviolet B (NB-UVB)
  • the combination treatment known as PUVA — (UVA) combined with a drug called psoralen for maximum effect
  • goeckerman therapy, which combines coal tar and UVB treatments
  • laser treatment such as Excimer laser for localized plaques of psoriasis

It should be noted that UV phototherapy is not for everyone. If your skin is sensitive to light or you cannot commit to traveling to an office 2 to 3 times per week for treatments (especially for NBUVB), discuss this with your physician.

There are also in-home phototherapy units that some insurance companies will cover.

Systemic treatments

Systemic drugs can be taken orally or by injection, and are often used for severe and resistant psoriasis. In regard to biologics, there’s increasing data that these medications can be used for a long time without any significantly increased risks.

In some individuals with certain treatments, over time your body may develop antibodies to the medications, which can make treatment less effective.

The most common non-biologic systemic treatments are methotrexate, acitretin (oral retinoid), and cyclosporine.

Methotrexate

Methotrexate is FDA-approved for the treatment of psoriasis in addition to other disorders. It interacts with the immune system and slows down the growth of skin cells to improve and prevent psoriatic skin disease. It is also used in the treatment of psoriatic arthritis.

Though it can be very effective, (and budget-friendly), it can cause serious potential side effects including liver damage and reduced production of blood cells and platelets. It is also strongly contraindicated in pregnancy.

Oral retinoids

Oral retinoids are vitamin A-based prescription drugs. They’re potent and generally prescribed only if the body hasn’t responded to other treatments.

Acitretin is currently the only FDA-approved oral retinoid, and side effects can be severe at high doses. Besides causing potential hair loss, it’s incredibly important to avoid this medication if you’re pregnant or may become pregnant within three years of treatment, as severe birth defects have been reported.

Cyclosporine

Cyclosporine is an oral immunosuppressant that’s sometimes used to treat severe, debilitating psoriasis.

Because cyclosporine suppresses your immune system, it can cause serious, sometimes fatal side effects (especially when used long term) — including cancer (particularly skin cancer) and a heightened risk for infection, kidney disease, and high blood pressure.

For this reason it’s usually only prescribed for short periods of time.

Biologics

Many biologics are FDA-approved for psoriasis and work by targeting the immune system, specifically T cells and their various secreted factors (interleukins), which play a big role in the development of psoriasis.

Similar to some of the systemic treatments mentioned above, biologics can cause an increased risk of infections, among other side effects. The body is also more likely to develop a resistance to certain biologics than other forms of treatment.

Biologics are an ever-increasing popular treatment for psoriasis because of their efficacy, increasing safety profile, and well-tolerated side effects.

Small molecules

Research has shown that small molecules can treat psoriasis in people whose symptoms have stopped responding to other forms of treatment.

Apremilast (Otezla) is currently the only FDA-approved small molecule medication on the market. It’s a pill that may help control symptoms of psoriatic arthritis and/or plaque psoriasis.

Patients have seen significant improvement in their symptoms after taking apremilast, and long-term safety data hasn’t indicated any serious side effects when used in appropriate individuals.

Bottom line

The “right” treatment for your psoriasis will evolve as your symptoms evolve. If you find your current medication is no longer working well — or at all — see your doctor.

There are many courses of treatment out there, and a medical professional will be able to help you navigate through them to pick the best option for you.