Immunomodulators for Psoriasis

Medically Reviewed by Stephanie S. Gardner, MD on March 29, 2022
7 min read

When you have psoriasis, your immune system sends out signals that cause your skin cells to renew themselves too fast. This too-active immune response is what makes scales and red patches form on your skin.

Immunomodulators work systemically, or throughout your body, to change your immune response. They are also known as disease-modifying antirheumatic drugs (DMARDs) because they can reduce or stop the effects psoriasis can have on your body.

If you have moderate to severe psoriasis, or if light therapy and medicines you spread on your skin don’t clear your skin, your doctor may prescribe an immunomodulator.

There are many different kinds of immunomodulators. Doctors have used some, such as methotrexate and cyclosporine, for many years. There are also a slew of newer types, such as the dozen or so biologics approved for psoriasis.

If one immunomodulator doesn’t clear or nearly clear your skin after you’ve taken it for the recommended amount of time, ask your doctor to prescribe something else. With so many treatment options for psoriasis, there’s no reason to live with its symptoms.

These are protein-based drugs created from living cells in a lab. They target the specific cells and proteins that create symptoms of psoriasis. These drugs are less likely to cause problems with your liver, kidneys, or other organs than drugs like methotrexate that suppress your entire immune system.

Biologics may stop working over time. If that happens, your doctor can recommend another biologic or switch you to another kind of immunomodulator.

Biologics are given as a shot or through intravenous (IV) infusion. Your doctor may suggest that you combine biologics with other treatments like topicals and light therapy.

Because they suppress some parts of your immune system, biologics can increase your risk for infections. That’s why your doctor will test you for tuberculosis and other infectious diseases before you begin treatment.

Don’t take biologics if you have an active infection or serious problems with your immune system. If you are older, have diabetes, smoke, or chew tobacco, your risk of developing a serious infection is higher.

Each of the many different biologics approved for psoriasis has its own potential side effects. Common ones include:

  • Headache
  • Flu-like symptoms
  • Upper respiratory tract infection
  • Urinary tract infection
  • Skin reactions where the IV or injection is placed

“Live” vaccines, or those that contain living viruses, can cause problems if you get them while you’re on a biologic. It’s best to get these vaccines before you start a biologic.

Talk to your doctor before you get any sort of vaccine, including a flu shot. It’s important to protect your health with the vaccines you need, however. Your doctor can usually adjust your psoriasis treatment so you can get vaccines safely.

You should also check with your doctor before you take any medication they haven't prescribed, including over-the-counter drugs.

This immunomodulator targets an enzyme in cells that controls inflammation. Unlike some other strong drugs for psoriasis, apremilast doesn’t cause serious side effects that require you to have medical tests while you take it.

Apremilast comes in pill form. Most often, you’ll increase your dose slowly over the first 5 days, working up to two 30-milligram tablets twice a day. This slow increase helps reduce side effects.

It’s important to swallow apremilast pills whole. Don’t chew, split, or crush them.

If you’re depressed, apremilast may make it worse. If you’re not, apremilast may cause depression or suicidal thoughts.

Don’t take apremilast if any of these apply to you:

  • Past or current depression
  • Pregnant or planning a pregnancy
  • Breastfeeding or plan to
  • Have other medical conditions
  • Have kidney disease

It can cause one or more of these side effects:

  • Headache
  • Runny nose
  • Sneezing
  • Nausea
  • Diarrhea
  • Vomiting
  • Respiratory tract infection
  • Weight loss

Some medications can change the way apremilast works or make serious side effects more likely. These include:

Check with your doctor before you mix apremilast with any other medication, vitamin, supplement, or herbal treatment.

Methotrexate lowers your immune system’s activity and blocks cells and enzymes that make your skin cells grow too quickly.

Your doctor can prescribe this drug in a pill or liquid form or as an injection you give yourself at home. Be sure to follow all instructions carefully and ask your doctor or pharmacist any questions you have before you start taking methotrexate.

Methotrexate can cause your white blood cell count to drop, which raises your risk of infection.

Liver damage is a serious concern with methotrexate. Your risk for this is higher if you:

  • Drink alcohol
  • Have kidney issues
  • Are obese
  • Have diabetes
  • Have had liver disease in the past

Your doctor will probably do blood tests every few months to make sure methotrexate isn’t damaging your liver or other organs.

In rare cases, methotrexate has caused certain types of cancer and bone marrow diseases.

Methotrexate is a strong medication that can cause birth defects. Anyone, man or woman, who takes methotrexate should stop it at least 3 months before they try to have children.

Don’t take methotrexate if you drink a lot of alcohol or have liver disease. You should also avoid it if you:

  • Have an infectious disease or HIV or another immune deficiency syndrome
  • Are trying to conceive a child
  • Are pregnant or nursing
  • Have a peptic ulcer
  • Have liver or kidney conditions

Have a low white blood cell count, anemia, low platelets, or bone marrow problems

Common side effects include:

  • Vomiting
  • Nausea
  • Loss of appetite
  • Sores, redness, or swelling in your mouth
  • Fatigue
  • Sun sensitivity

A folic acid supplement may reduce some minor side effects. Track any side effects you notice and share them with your doctor.

Don’t take methotrexate at the same time as antibiotics that contain trimethoprim-sulfa.

If you’re prescribed one of these antibiotics, talk to your doctor about how to schedule it with your methotrexate dose. They will probably ask you to hold your methotrexate during treatment with this kind of antibiotic.

This drug was originally used to prevent organ rejection after a transplant. Doctors noticed that when they gave cyclosporine to transplant patients who also had psoriasis, it helped clear their skin. It’s used most often for people with severe or disabling psoriasis and tends to work quickly.

Cyclosporine comes in pill or liquid form. You have to take it consistently for it to work. You also need to dilute liquid cyclosporine with orange or apple juice before you take it. Never mix it with grapefruit juice, which can cause your body to absorb too much of the drug.

You may start out with a low dose and increase it or start out with a higher dose and decrease it. Make sure you know what your dose is and when to take it before you start this drug.

Cyclosporine raises your risk for skin cancer if you’ve:

  • Taken methotrexate or any other immunomodulator
  • Had PUVA or UVB therapy
  • Had coal tar treatment
  • Had radiation

Cyclosporine also raises your risk for kidney damage. Your doctor will track your kidney function before and during treatment. It can also cause high blood pressure, so you and your doctor should check that regularly, too.

Talk to your doctor before you get any kind of vaccination, including a flu shot. Vaccines may be less effective when you’re taking cyclosporine.

Cyclosporine is not the right drug for you if you are pregnant, breastfeeding, doing radiation treatment, or have:

  • High blood pressure
  • A kidney condition
  • Low immune system function
  • Cancer, present or past
  • Severe gout

Cyclosporine has a range of side effects. Minor ones include:

  • Headache
  • Fatigue
  • Nausea or stomach issues
  • Flu-like symptoms
  • Bone, muscle or joint pain
  • Sensitive skin
  • Tingling or burning in your arms or legs

This drug can also make your hair and gum tissues grow more than usual.

More serious side effects include low kidney function, high blood pressure, or high cholesterol. Expect your doctor to monitor you closely for all three conditions.

Cyclosporine interacts with many different kinds of medications. Make sure your doctor knows about every medication you take, including supplements and over-the-counter drugs. Check first before taking any kind of:

  • Aspirin, Ibuprofen, or other anti-inflammatory drug
  • Antibiotics
  • Anticonvulsants
  • Antifungals
  • Calcium channel blockers
  • Gastrointestinal medications

Steer clear of grapefruit, which decreases your body’s ability to process cyclosporine.

Cyclosporine can increase the amount of potassium in your blood. Ask your doctor if it’s OK to eat potassium-filled foods like bananas, tomatoes, raisins, and carrots.