If you’ve been living with psoriasis for a while, you may already know how unpredictable and stubborn it can be. You might have tried topical creams, light therapy, or over-the-counter remedies and still found that your symptoms return just as quickly as they calm down. Many people reach a point where creams simply aren’t enough, and that is often when the question arises: Is it time for systemic treatment?
Understanding when dermatologists recommend systemic therapies can help you make sense of your treatment options and feel more in control of your psoriasis journey. You may be wondering whether your psoriasis is “severe enough,” whether tablets or biologics are safe, or what criteria specialists use to decide when escalation is appropriate.
If you decide to seek specialist support, it can be reassuring to know that services such as a psoriasis clinic in London offer personalised assessments based on the most up-to-date clinical guidelines.
Why Psoriasis Sometimes Needs More Than Creams
Topical treatments are usually the first step in managing psoriasis. They work well for small patches or mild inflammation, and they can give quick relief from itching, redness, and scaling. But they only work on the surface of your skin. Psoriasis, however, begins deep within your immune system.
If the inflammation driving your psoriasis is strong enough, topical treatments may not be able to calm it effectively. You might notice that the plaques return as soon as you stop applying a cream, that the patches keep spreading, or that the symptoms simply don’t settle regardless of how consistent you are.
This mismatch between immune activity and surface-level treatment is the main reason dermatologists consider systemic therapy. When the messages coming from your immune system remain overactive, targeting the skin alone won’t be enough.
Understanding Psoriasis Severity: How Dermatologists Measure It
Dermatologists use several tools to determine the severity of psoriasis. These measurements guide treatment decisions, including whether systemic therapy may be appropriate. Even if your psoriasis doesn’t appear severe to you, it might score highly based on medical criteria especially if it affects sensitive areas or impacts your daily life.
Key tools dermatologists use include:
PASI Score (Psoriasis Area and Severity Index)
- Combines the thickness, redness, and scaling of plaques with the percentage of body affected.
- Higher scores indicate more severe psoriasis and may prompt consideration of stronger treatments.
BSA Assessment (Body Surface Area)
- Measures the percentage of your skin covered by psoriasis plaques.
- The palm of your hand roughly represents 1% of your body surface.
- Systemic treatment is often considered when psoriasis affects more than 10% of your body, though location and impact on function also matter.
DLQI (Dermatology Life Quality Index)
- A questionnaire that measures how psoriasis affects daily life, including sleep, self-confidence, relationships, and work.
- A high DLQI score can be as important as a high PASI score, showing the real-life impact even when coverage is limited.
Together, these tools help dermatologists build a comprehensive understanding of your psoriasis, enabling them to choose the most effective treatment. They ensure that both the physical and emotional effects of psoriasis are considered, not just the visible plaques.
When Mild Psoriasis Still Needs Systemic Treatment
Many people are surprised to learn that psoriasis doesn’t have to be widespread for systemic treatment to be recommended. If your psoriasis affects certain sensitive or high-impact areas, even small patches can cause major difficulties and impact your quality of life.
Key considerations include:
Scalp psoriasis
- Thick or widespread plaques can be difficult for topical treatments to penetrate effectively.
- Itching, flaking, and visible plaques can be socially and physically uncomfortable.
Facial psoriasis
- Even small patches on the face can be highly visible and affect self-confidence.
- Sensitive skin may limit the use of potent topical treatments.
Genital psoriasis
- This area is prone to irritation and discomfort.
- Topical options are limited due to sensitivity, making systemic therapy more effective.
Nail psoriasis
- Can cause pain, discolouration, crumbling, or difficulty performing daily activities.
- Topical treatments often struggle to reach the nail matrix, reducing effectiveness.
Palms and soles
- Thick plaques can interfere with walking, gripping, or daily tasks.
- These areas are hard to treat topically, and discomfort can be severe.
Psoriasis in these areas may be classified as severe because it significantly affects your quality of life, even if overall body coverage is low. In such cases, systemic treatment may be recommended sooner.
The Rule of Tens: A Clear Guide for Escalation
Dermatologists often use a simple guideline called the “rule of tens” when assessing whether systemic treatment is appropriate. According to this rule, psoriasis may qualify for systemic therapy if:
- Your PASI score is higher than 10
- Your BSA is greater than 10%
- Or your DLQI score is more than 10
If you meet any one of these criteria, your psoriasis may be considered moderate-to-severe and unsuitable for topical treatment alone.
This rule helps dermatologists make consistent decisions across different types of psoriasis and different patient situations. It also reassures you that the decision to escalate treatment is not arbitrary but based on internationally recognised criteria.
When Psoriasis Doesn’t Respond to Topicals
Sometimes the reason for escalating treatment is simple: topical therapy isn’t working. You might be applying creams exactly as prescribed and still find that your psoriasis remains stubborn. Dermatologists call this “refractory psoriasis,” meaning it resists standard topical treatment.
This lack of response suggests that inflammation is too strong for topical treatment alone. It indicates that your immune system is playing a bigger role than your current treatment can manage.
If your psoriasis keeps returning or never fully clears, even with consistent topical use, systemic therapy may offer the more effective option. Targeting the immune system rather than only the skin can lead to a deeper, more long-lasting improvement.
When Psoriasis Spreads Quickly
Psoriasis can sometimes spread rapidly, especially during flare-ups triggered by infection, stress, cold weather, or injury. Guttate psoriasis, for example, often appears suddenly in small, drop-shaped patches across the body after a streptococcal throat infection.
Rapidly progressing psoriasis suggests that immune activity is accelerating. In these cases, dermatologists sometimes recommend systemic treatment early because the inflammation is too active to manage with creams alone. The aim is to regain control quickly before the patches become widespread.
Psoriatic Arthritis: A Key Reason to Start Systemic Treatment
If you develop psoriatic arthritis, systemic treatment becomes especially important. Psoriatic arthritis can cause permanent joint damage if left untreated. Topical psoriasis treatments have no effect on joint inflammation, which is driven by the immune system in a similar way to skin psoriasis.
Symptoms of psoriatic arthritis include:
- Joint pain or stiffness
- Swelling of fingers or toes
- Lower back pain
- Reduced range of movement
- Morning stiffness that improves during the day
If you have any of these signs, it’s essential to discuss systemic treatment with your dermatologist. Early intervention can prevent long-term joint damage and significantly improve your quality of life.
Biologic treatments, in particular, can treat both psoriasis and psoriatic arthritis at the same time, making them an excellent option for people with both conditions.
When Psoriasis Causes Emotional or Social Distress
Psoriasis is not just a physical condition. For many people, the psychological and social effects are just as significant as the physical symptoms. Living with visible plaques, persistent itching, or uncomfortable flare-ups can affect your self-esteem, relationships, work, social life, and emotional wellbeing.
Dermatologists consider the emotional impact of psoriasis when deciding whether systemic treatment is appropriate. If your psoriasis makes you avoid social situations, feel self-conscious, struggle at work, or experience anxiety or depression, your dermatologist may recommend systemic therapy even if your physical symptoms appear moderate.
Clearing the skin often leads to an improvement in emotional wellbeing. Recognising the psychological effect is an important part of holistic psoriasis care.
When Light Therapy Doesn’t Work or Isn’t Suitable
Phototherapy is a very effective treatment for many people with moderate psoriasis. It uses ultraviolet light to slow down skin cell turnover and calm inflammation. But it doesn’t work for everyone, and it is not always practical.
You may need systemic treatment if:
- Phototherapy isn’t improving your symptoms
- Your psoriasis returns immediately after therapy
- You live too far from a treatment centre to attend multiple sessions a week
- You have certain medical conditions that make UV therapy unsuitable
Phototherapy requires regular attendance at a clinic, often two or three times a week for several weeks. For some people, this simply isn’t realistic. In such cases, systemic treatment offers a more practical, long-lasting alternative.
When Certain Types of Psoriasis Require Early Systemic Treatment
Some forms of psoriasis are more aggressive or harder to control and may warrant earlier systemic therapy.
Pustular psoriasis, erythrodermic psoriasis, and severe scalp or nail psoriasis are prime examples. These types of psoriasis often respond poorly to topicals and require a more targeted approach.
Erythrodermic psoriasis can be dangerous as it affects large areas of the skin and can lead to complications such as dehydration or temperature regulation issues. Pustular psoriasis can be painful and may require urgent systemic treatment to reduce inflammation.
Nail psoriasis is particularly stubborn and rarely clears with topical therapies alone because the medication cannot penetrate deep enough. Systemic treatments offer a much more effective way of addressing these types of psoriasis.
Systemic Treatment Options: What Dermatologists Use and Why
Systemic treatments work throughout your body, targeting the immune system directly rather than the skin alone. Dermatologists have several options to choose from, depending on your type of psoriasis, your health, and your treatment history.
Conventional systemic medications such as methotrexate, ciclosporin, and acitretin have been used for many years. They help calm inflammation but may affect other parts of the immune system, which means you’ll need regular monitoring.
Modern biologic treatments are different. They focus on specific immune pathways such as IL-17, IL-23, and TNF. By targeting only the pathways involved in psoriasis, they offer powerful and long-lasting improvements with fewer side effects.
Newer oral treatments such as apremilast act on intracellular pathways to reduce inflammation without the same level of immune suppression as older systemic drugs.
Your dermatologist will help you decide which treatment is right for you based on your symptoms, medical history, and preferences.
The Safety of Systemic Treatments
Many people feel worried about the idea of taking tablets or injections that affect the immune system. It’s normal to have concerns about side effects or long-term risks. But modern systemic treatments are designed with precision, and your dermatologist will monitor your health closely to ensure your safety.
Biologic treatments, in particular, target very specific parts of the immune system rather than suppressing it entirely. This makes them safer and more predictable than older systemic drugs. Regular check-ups and blood tests help ensure that your treatment remains safe and effective.
Dermatologists have extensive experience using these medications and will always balance potential risks against the benefits of clearer skin and improved quality of life.
The Importance of Support From Dermatology Specialists
Making the decision to start systemic treatment can feel overwhelming, especially when you’re thinking about long-term health and safety. That’s why it’s so important to have support from dermatology experts who understand the condition and the treatments available.
Services like a psoriasis clinic in London offer comprehensive assessments, personalised treatment plans, and access to advanced therapies such as biologics. Having specialist support helps you make informed decisions with confidence.
Working with a dermatologist ensures that your treatment is tailored to your needs and monitored closely to keep you safe.
FAQs:
1. When should I consider systemic treatment for psoriasis?
Systemic treatment is typically considered when topical therapies and light-based treatments are no longer effective at controlling symptoms. Dermatologists assess factors such as the severity of skin involvement, the areas affected, the impact on daily life, and whether psoriasis is progressing rapidly. Even if psoriasis covers a small body surface area, involvement of sensitive regions like the scalp, face, nails, or genitals, or significant emotional distress, may prompt the use of systemic therapy. The goal is to achieve deeper, long-lasting control of inflammation by targeting the immune system directly.
2. How do dermatologists decide whether systemic therapy is appropriate?
Specialists use objective tools like the PASI (Psoriasis Area and Severity Index) score, BSA (Body Surface Area) measurement, and DLQI (Dermatology Life Quality Index) questionnaire to assess psoriasis severity. They also evaluate treatment history, response to topicals, and the presence of complications such as psoriatic arthritis. These combined assessments allow dermatologists to determine whether a patient would benefit from tablets, injections, or biologic therapies. The decision is guided by internationally recognised criteria, ensuring that systemic treatment is prescribed when the potential benefits outweigh the risks.
3. Are systemic treatments safe for long-term use?
Modern systemic therapies are generally considered safe for long-term use when monitored appropriately by a dermatologist. Biologics, in particular, target specific immune pathways such as IL-17, IL-23, and TNF, reducing the risk of widespread immune suppression. Regular check-ups and laboratory tests help monitor liver function, kidney function, and immune system activity, ensuring safety over time. While minor side effects such as mild infections can occur, these are usually manageable, and the benefits of controlling moderate-to-severe psoriasis often outweigh the risks.
4. How quickly do systemic treatments work?
The speed of improvement depends on the type of treatment and the immune pathway it targets. IL-17 inhibitors are often fast-acting, with patients noticing reduced redness and plaque thickness within weeks. IL-23 inhibitors generally work more gradually but produce longer-lasting remissions by acting upstream in the inflammatory cascade. Conventional systemic medications such as methotrexate or ciclosporin may take a few months to show full effect, whereas biologics frequently provide visible improvement sooner while maintaining longer-term control.
5. Can systemic treatments help if I have psoriatic arthritis?
Yes, many systemic therapies are effective for both skin and joint symptoms. Biologics and certain conventional medications, such as methotrexate and TNF inhibitors, reduce inflammation in joints as well as skin. Treating psoriatic arthritis early is critical to prevent permanent joint damage, improve mobility, and reduce pain. By targeting the immune pathways that drive both skin and joint disease, systemic treatments can provide comprehensive control and improve overall quality of life.
6. Are there types of psoriasis that require earlier systemic treatment?
Certain forms of psoriasis, such as pustular psoriasis, erythrodermic psoriasis, and severe scalp or nail psoriasis, may require systemic therapy sooner. These types are often resistant to topical treatments and can cause complications if left untreated. Erythrodermic psoriasis, in particular, can be life-threatening due to widespread inflammation affecting temperature regulation and hydration. Systemic therapy provides a faster, more effective means to control these aggressive forms of the condition and prevent severe outcomes.
7. What role does quality of life play in deciding on systemic therapy?
Psoriasis can affect emotional wellbeing, social interaction, work, and self-esteem. Even if plaques are limited, the psychological impact may be significant. Dermatologists consider how symptoms affect daily life, including sleep, confidence, and social participation, when deciding whether to escalate treatment. Improving quality of life is a primary goal, and systemic therapy may be recommended to address both physical and emotional burdens.
8. How do systemic treatments compare to topical creams?
Topical creams act only on the skin’s surface, temporarily reducing redness, scaling, and itching. They do not affect the underlying immune activity driving psoriasis. Systemic treatments, on the other hand, work throughout the body to calm immune-driven inflammation, helping to prevent flare-ups and promote sustained skin clearance. By addressing the root cause rather than just the surface symptoms, systemic therapy can produce deeper, longer-lasting improvements than topical therapy alone.
9. What should I expect in terms of monitoring while on systemic treatment?
Patients on systemic therapy usually undergo regular check-ups and laboratory tests to monitor safety and efficacy. Blood tests may track liver and kidney function, blood cell counts, and immune system activity. Dermatologists may also assess skin response, check for infections, and adjust doses as needed. This close monitoring ensures the treatment remains safe, effective, and tailored to the individual’s needs, minimising the risk of complications while maximising skin and joint improvement.
10. How do I know which systemic treatment is right for me?
The choice of systemic therapy depends on multiple factors, including the type and severity of psoriasis, previous treatment response, presence of psoriatic arthritis, comorbidities, lifestyle considerations, and patient preference. Dermatologists discuss these factors in detail, explaining the expected benefits, potential side effects, and administration method (oral, injection, or infusion). Personalised treatment plans allow patients to achieve the best possible outcome while maintaining safety and quality of life.
Final Thought: When Systemic Treatment Becomes the Right Choice
Systemic treatment isn’t just for the most severe cases of psoriasis it’s for anyone whose symptoms are no longer manageable with creams, light therapy, or lifestyle changes alone. Dermatologists look closely at immune activity, quality-of-life impact, and specific high-impact areas like the scalp, nails, face, and genitals before recommending stronger therapy. When inflammation runs deeper than the skin, targeting the immune pathways directly can offer clearer, more stable, and longer-lasting results. If you’re considering psoriasis clinic in London, you can contact us at London Dermatology Centre to book a consultation with one of our specialists.
References:
1. Assessment of TNF-α, IL-12/23, and IL-17 in Psoriasis: Only TNF-α Reflects Clinical Response After 12 Weeks of Biologic Treatment shows how biologic treatment reduces key cytokines (TNF-α, IL-12/23, IL-17) and correlates with clinical improvement (PASI, DLQI). https://www.mdpi.com/1467-3045/47/5/368
2. Advances in Psoriasis Research: Decoding Immune‑Mediated Mechanisms and Therapy reviews modern biologic and systemic strategies targeting immune pathways for long-term disease control. https://www.mdpi.com/1422-0067/26/18/9233
3. Therapeutic Advances in Psoriasis: From Biologics to Emerging Treatments a comprehensive overview of systemic options including biologics, small-molecule drugs, and evolving therapies for moderate-to-severe psoriasis. https://pmc.ncbi.nlm.nih.gov/articles/PMC11417777/
4. Psoriasis: An Update on Topical and Systemic Therapies discusses when systemic therapy becomes necessary, and summarises efficacy and safety compared with topical treatments. https://pmc.ncbi.nlm.nih.gov/articles/PMC12187478/
5. Advancing Insights into Psoriasis: From Pathogenesis to Systemic and Biologic Therapy highlights newest biological drugs and evolving treatment guidelines for systemic therapy in psoriasis. https://www.sciencedirect.com/science/article/pii/S1567576925014201