Treating Psoriasis

Expert Evaluation and Evidence-Based Management

Thick, scaly patches on your elbows and knees that never seem to fully clear. Plaques on your scalp that shed silvery scale. Pitted, discolored nails. Stiff, painful joints that arrived alongside your skin condition. Psoriasis is far more than a surface problem, and if you’ve been managing it with whatever’s on the pharmacy shelf, you’re likely only scratching the surface of what effective treatment can achieve.

Psoriasis is a chronic, immune-mediated inflammatory disease affecting approximately 125 million people worldwide, including roughly 2 to 3 percent of the United States population. It is driven by a dysregulated interaction between the innate and adaptive immune systems that triggers uncontrolled keratinocyte proliferation. Normal skin cells take about 28 days to mature and shed. In psoriasis, that cycle collapses to 3 to 5 days, producing the characteristic plaques that define the condition.

At Connolly Dermatology, we provide expert evaluation and psoriasis treatment guided by evidence-based care. Our board-certified dermatologists accurately diagnose your psoriasis subtype, assess severity using validated clinical tools, screen for psoriatic arthritis and systemic comorbidities, and design a treatment plan that matches the full complexity of your disease. From topical therapy and phototherapy through advanced biologics and oral small molecules, we offer the complete spectrum of evidence-supported interventions.

If psoriasis is affecting your skin, your joints, or your quality of life, a dermatologic evaluation is the most important step you can take. Have your skin assessed by the specialists at Connolly Dermatology and get the answers you need to move forward confidently.

Understanding Psoriasis

How Psoriasis Differs From Eczema and Other Inflammatory Skin Conditions

Psoriasis is an immune-mediated genetic skin disease. Its central mechanism involves dendritic cell activation that drives the differentiation of Th1, Th17, and Th22 T-helper cell populations. The Th17 pathway is the most therapeutically significant, producing the inflammatory cytokines IL-17 and IL-22 that stimulate keratinocytes to proliferate abnormally and generate the thick, silvery-scaled plaques that define the disease. This molecular understanding has transformed treatment over the past two decades, enabling the development of biologic agents that target these specific inflammatory pathways with extraordinary precision.

Psoriasis follows a chronic relapsing-remitting course. Most patients experience periods of flare followed by partial or complete remission. Triggers including infections, physical trauma, stress, and certain medications can initiate or worsen flares. The Koebner phenomenon, the development of new psoriatic lesions at sites of skin injury, reflects the active inflammatory state of the disease and underscores why skin protection matters.

Psoriasis affects multiple organ systems beyond the skin. Up to 30 percent of patients develop psoriatic arthritis, a chronic inflammatory joint disease that can cause progressive joint destruction without appropriate treatment. The skin disease and joint disease don’t always track together in severity, which is why every psoriasis evaluation includes systematic arthritis screening.

Types of Psoriasis

Plaque Psoriasis (Psoriasis Vulgaris): Accounts for approximately 85 to 90 percent of all psoriasis cases. Characterized by well-demarcated, erythematous plaques covered with thick, silvery-white scale on an erythematous base. Lesions appear most commonly on the extensor surfaces of the elbows and knees, the scalp, and the lumbosacral region. Itching ranges from absent to severe. The Auspitz sign, pinpoint capillary bleeding when the scale is removed, is a clinically useful diagnostic feature.

Guttate Psoriasis: Presents as a sudden eruption of numerous small, raindrop-shaped plaques measuring 0.5 to 1.5 centimeters across, typically scattered across the trunk and back. It predominantly affects children and young adults and most commonly follows a streptococcal upper respiratory infection by 2 to 3 weeks. Guttate psoriasis carries the best prognosis of all subtypes; many cases resolve completely within months, though some progress to chronic plaque psoriasis.

Inverse Psoriasis (Flexural Psoriasis): Produces smooth, brightly erythematous, sharply demarcated patches in skin folds, including the axillae, groin, inframammary regions, umbilicus, and intergluteal cleft. Because friction and moisture prevent scale formation, these lesions lack the characteristic silvery surface of plaque psoriasis. They can be moist, macerated, and prone to secondary Candida colonization. Diagnosis requires distinguishing from fungal and bacterial infections of the same sites.

Pustular Psoriasis: Characterized by sterile, non-infectious pustules on an erythematous base. The generalized form (von Zumbusch) involves widespread erythema and confluent pustules with systemic illness including fever, leukocytosis, and electrolyte disturbances. It is potentially life-threatening and requires urgent systemic management. Localized subtypes include palmoplantar pustulosis, producing deep, painful pustules on the palms and soles.

Erythrodermic Psoriasis: The most severe and potentially life-threatening subtype. Erythema and superficial desquamation cover more than 75 to 90 percent of the body surface. Patients experience fever, chills, malaise, significant fluid losses through the disrupted skin barrier, and risk of cardiac failure from high-output hemodynamic stress. It requires inpatient management in severe cases and urgent systemic therapy.

Nail Psoriasis: Affects 30 to 50 percent of psoriasis patients and up to 90 percent of those with psoriatic arthritis. Clinical findings include pitting, oil-spot discoloration, subungual hyperkeratosis, onycholysis (nail plate separation), and nail dystrophy. Nail psoriasis is notoriously difficult to treat and serves as a strong predictive marker for psoriatic arthritis development.

Scalp Psoriasis: A common and often distressing site of involvement, frequently the first or only location affected. Plaques extend beyond the hairline onto the forehead, nape, and ears. Thick scale and pruritus are prominent. Hair loss is temporary and results from vigorous scratching rather than the psoriasis itself.

Psoriasis vs. Similar Skin Conditions

Psoriasis shares surface features with several other inflammatory skin conditions. Accurate diagnosis determines whether treatment targets Th17-driven keratinocyte hyperproliferation, Th2-driven barrier dysfunction, or a completely different mechanism. The table below highlights key clinical distinctions.

This table reflects typical presentations. Clinical overlap occurs. A dermatologist provides the definitive diagnosis when features are ambiguous or when a condition does not respond as expected.

Is Psoriasis Dangerous?

Psoriasis is not contagious and does not become cancerous in its typical form. However, framing it as merely a cosmetic condition profoundly understates its medical significance.

Psoriasis is a systemic inflammatory disease. The chronic, low-grade systemic inflammation that drives skin plaques also contributes to an independently elevated risk of cardiovascular disease, myocardial infarction, stroke, type 2 diabetes, metabolic syndrome, and non-alcoholic fatty liver disease. Psoriatic arthritis, present in up to 30 percent of patients, causes progressive, destructive joint damage that leads to permanent disability in approximately 10 percent without appropriate treatment. Generalized pustular psoriasis and erythrodermic psoriasis are genuine medical emergencies. Depression and anxiety affect a disproportionate share of psoriasis patients, driven by the chronic, visible, and unpredictable nature of the disease. These are not incidental findings. They are direct consequences of undertreated systemic inflammation.

Signs and Symptoms of Psoriasis

Psoriasis presents across an exceptionally wide spectrum of appearances, body locations, and severity levels. Its manifestations vary significantly by subtype, body site, and skin tone. Understanding what to look for helps you recognize the condition earlier and communicate accurately with your dermatologist.

The Classic Plaque: What It Looks Like

The hallmark of psoriasis vulgaris is a well-demarcated, raised, erythematous plaque covered with thick, silvery-white, micaceous scale. The sharp, clearly defined border distinguishes psoriatic plaques from the poorly defined, blurring lesions of eczema. Plaques are palpable, often elevated several millimeters above the surrounding skin. In fair skin they appear salmon-pink to bright red; in darker skin tones they present as violaceous or brown plaques. The scale itself reflects the underlying accelerated keratinocyte turnover and is a direct visual representation of the dysregulated immune-driven proliferation driving the disease.

The Auspitz Sign

Removing the scale of a psoriatic plaque by gently scraping reveals pinpoint bleeding points from dilated, tortuous dermal capillaries beneath the thinned epidermis. This is the Auspitz sign. It is one of the most reliable bedside diagnostic features of psoriasis and reflects the vascular architecture characteristic of psoriatic plaques. No other common inflammatory skin condition consistently produces this finding.

Itch and Discomfort

Pruritus is variable in psoriasis. Many patients describe mild to moderate itch. Others experience severe, sleep-disrupting itching that drives the scratching and Koebnerization that perpetuates and spreads the disease. Burning and pain are more common in inverse and palmoplantar psoriasis, where fissuring in skin folds and on pressure-bearing plantar surfaces can be intensely painful and functionally disabling.

Nail Changes

Nail involvement is present in 30 to 50 percent of psoriasis patients and is one of the strongest predictors of developing psoriatic arthritis. Pitting, which appears as small ice-pick depressions in the nail surface, is the most common nail finding. Oil spots, a yellow-brown discoloration visible through the nail plate, represent psoriatic involvement of the nail bed. Subungual hyperkeratosis produces thickening and crumbling under the nail. Onycholysis, the separation of the nail plate from the nail bed, is also common. These changes are often mistaken for fungal nail infection and require careful clinical or laboratory differentiation.

Scalp Involvement

Scalp psoriasis frequently precedes or accompanies skin psoriasis and is often misidentified as severe dandruff or seborrheic dermatitis. Thick, adherent scale covers the scalp and typically extends beyond the hairline onto the forehead, nape, and ears. The overlying hair is not directly affected by psoriasis, but vigorous scratching can cause temporary hair loss that resolves with disease control.

Joint Symptoms

Psoriatic arthritis manifests as joint pain, swelling, stiffness, and tenderness, most commonly affecting the fingers and toes in an asymmetric pattern. Dactylitis, the sausage-like swelling of an entire digit, is a characteristic finding. Enthesitis, inflammation at tendon and ligament insertion points, causes heel pain, Achilles tendon tenderness, and chest wall discomfort. Spinal involvement produces inflammatory back pain that is worse with rest and improves with activity. Joint symptoms can precede, accompany, or follow skin disease and don’t always correlate in severity with the skin.

Impact on Daily Life

Psoriasis imposes a daily burden that extends far beyond what is visible. Scale shedding on clothing and bedding creates social self-consciousness. Time-consuming topical treatment application becomes part of daily routines. Avoidance of swimming, physical activity, and social situations is common. The chronic, unpredictable nature of flares generates persistent anxiety. Published research consistently documents rates of depression, anxiety, and social withdrawal in psoriasis patients that parallel those seen in patients with serious systemic diseases.

Symptoms To Watch For

Psoriasis is a progressive disease with systemic implications. Certain presentations and changes indicate that professional evaluation and more targeted management are overdue. See a dermatologist if you notice:

•         Well-defined, scaly plaques on the elbows, knees, scalp, or lower back that persist or recur
•         Nail pitting, oil spots, thickening, or nail plate separation
•         Painful, swollen joints, dactylitis, or heel pain accompanying skin lesions
•         A sudden eruption of widespread small plaques, particularly following a sore throat
•         Pustules on the palms, soles, or widespread across the body
•         Rapidly worsening, widespread redness covering large portions of the body
•         Skin disease significantly affecting your work, social life, or mental health
•         Any skin condition that has not responded to over-the-counter treatments

Earlier diagnosis and treatment initiation prevent joint destruction, reduce cardiovascular risk, and produce substantially better long-term skin outcomes than delayed intervention.

Risk Factors for Developing Psoriasis

Psoriasis results from a complex interaction between genetic predisposition and environmental exposures. No single factor causes it. But understanding the risk landscape helps explain why the condition develops in some people and not others, and why certain individuals experience more severe or persistent disease.

Genetics and Family History

The genetic contribution to psoriasis is among the strongest of any common inflammatory skin disease. Having a first-degree relative with psoriasis roughly doubles the lifetime risk. If both parents are affected, the risk approaches 50 percent. The PSORS1 locus on chromosome 6p21, within the major histocompatibility complex, carries the greatest single genetic influence on psoriasis susceptibility. The HLA-Cw6 allele is specifically associated with early-onset Type 1 psoriasis and with guttate psoriasis following streptococcal infection. More than two dozen genetic susceptibility loci have been identified, most of them linked to immune system function.

Age and Onset Pattern

Psoriasis displays a bimodal age distribution. The first peak occurs between ages 15 and 20 years, representing the genetically driven early-onset form (Type 1) with strong HLA-Cw6 association and positive family history. The second peak occurs between ages 55 and 60, representing late-onset psoriasis (Type 2) without HLA association and typically less severe family history involvement. Psoriasis can present at any age, including childhood and very late adulthood, but these two windows represent the highest probability periods.

Infections

Streptococcal upper respiratory tract infections are one of the most well-established and clinically important triggers for psoriasis. Group A beta-hemolytic streptococci trigger guttate psoriasis in genetically susceptible individuals and can precipitate or worsen plaque psoriasis flares. Viral infections including HIV are also associated with more aggressive and treatment-resistant disease. Monitoring and promptly treating streptococcal infections in psoriasis patients is a meaningful disease management strategy.

Physical Trauma and the Koebner Phenomenon

New psoriatic plaques develop at sites of skin trauma in a process called the Koebner phenomenon. Cuts, abrasions, sunburn, surgical incisions, tattoos, and even aggressive scratching can trigger new lesion formation within 10 to 20 days. The Koebner response is a marker of active disease and an important reason to protect the skin from unnecessary injury during flares. Ironically, moderate sun exposure is generally beneficial for psoriasis and suppresses inflammation, unlike rosacea and eczema.

Medications

Several medications are established psoriasis triggers or exacerbants. Beta-blockers, lithium, chloroquine and hydroxychloroquine, NSAIDs, ACE inhibitors, and terbinafine are the most commonly implicated. Systemic corticosteroids warrant special mention: while they produce rapid, dramatic psoriasis clearance, abrupt withdrawal commonly precipitates severe rebound flares or pushes plaque psoriasis into the more dangerous pustular or erythrodermic forms. For this reason, systemic corticosteroids are strongly discouraged in psoriasis management by current clinical guidelines.

Lifestyle Factors

Tobacco smoking, excessive alcohol consumption, and obesity are all independently associated with both psoriasis onset and disease severity. Obesity is particularly clinically significant. Adipose tissue is a pro-inflammatory organ that amplifies the systemic inflammatory burden already present in psoriasis. Research shows that meaningful weight loss, through dietary modification, exercise, or bariatric surgery, reduces psoriasis severity and improves treatment response to biologics. Smoking worsens psoriasis directly and reduces the efficacy of biologic therapy.

Psychological Stress

Psychological stress is a well-recognized psoriasis trigger, though the precise mechanism remains incompletely understood. Neuropeptides released during stress, including substance P and nerve growth factor, activate mast cells and promote keratinocyte proliferation. Many patients identify major life stressors as the precipitant of their first psoriasis episode or most significant flare. Stress management is a clinically relevant, evidence-supported adjunct to dermatologic treatment.

Can You Prevent Psoriasis?

Psoriasis cannot be prevented when genetic predisposition is present. However, modifiable lifestyle factors and trigger avoidance meaningfully reduce flare frequency, improve treatment response, and limit the systemic cardiovascular and metabolic burden the disease carries.

Protect the Skin Barrier

Consistent moisturizer use reduces skin dryness that lowers the flare threshold and helps prevent the Koebner response from minor skin trauma. Avoiding hot water, harsh soaps, and skin-irritating fabrics reduces unnecessary inflammatory activation.

Address Modifiable Risk Factors

Maintaining a healthy body weight, limiting alcohol consumption, and stopping tobacco use all reduce psoriasis severity independently of medical treatment. These interventions also reduce cardiovascular risk, which is significantly elevated in moderate to severe psoriasis patients.

Manage Streptococcal Infections Promptly

Sore throats that trigger psoriasis flares should be evaluated and treated if streptococcal. Recurrent streptococcal pharyngitis driving recurrent guttate or plaque psoriasis flares may warrant discussion of tonsillectomy with an otolaryngologist.

Seek Regular Dermatologic Monitoring

Routine appointments allow your dermatologist to screen for psoriatic arthritis, assess cardiovascular and metabolic comorbidities, track disease severity over time, and adjust treatment before the disease progresses to a more difficult-to-manage stage.

Diagnosis and Evaluation of Psoriasis

Psoriasis is a clinical diagnosis. The characteristic morphology and distribution of lesions are usually sufficient for an experienced dermatologist to confirm the diagnosis with confidence. Laboratory testing and biopsy are rarely needed for classic presentations. However, a comprehensive dermatologic evaluation does far more than simply confirm the diagnosis. It characterizes your subtype, quantifies severity, screens for psoriatic arthritis, assesses cardiovascular and metabolic comorbidities, and establishes the baseline measurements used to track your treatment response.

During your appointment, your dermatologist uses a systematic approach to ensure nothing is missed and your treatment plan is built on complete information.

Clinical Examination

Your dermatologist examines your skin thoroughly, assessing the distribution, morphology, and extent of plaques. They evaluate the scalp, nails, palms, soles, and flexural areas, all common sites that require specific treatment approaches. The presence of the Auspitz sign is noted. Associated features including the Koebner phenomenon, nail changes, and the distribution pattern help confirm the subtype. Your history of onset, flare triggers, prior treatments and their responses, and family history of psoriasis and arthritis all contribute to the clinical assessment.

Severity Assessment

Severity grading directly determines treatment selection. Your dermatologist uses validated clinical tools to classify your psoriasis objectively. The Psoriasis Area and Severity Index (PASI) is the most widely used research tool, scoring erythema, induration, scaling, and affected body surface area across four regions. Body Surface Area (BSA) assessment quantifies the percentage of skin involved. The Physician Global Assessment (PGA) provides a simplified overall severity rating. The Dermatology Life Quality Index (DLQI) captures the impact of psoriasis on daily functioning, sleep, social activity, and work. These measurements establish your baseline and enable precise monitoring of treatment response at follow-up visits.

Psoriatic Arthritis Screening

Every psoriasis patient is systematically screened for psoriatic arthritis at each visit. Your dermatologist asks specifically about joint pain, stiffness, swelling, dactylitis, and inflammatory back pain. Validated screening tools including the Psoriasis Epidemiology Screening Tool (PEST) are used to identify patients at elevated risk. Patients with suspicious findings are referred to a rheumatologist for formal evaluation. Early identification of psoriatic arthritis is critical because untreated joint inflammation causes irreversible structural damage that cannot be undone with even the most advanced therapy.

Comorbidity Assessment

Given psoriasis’s well-documented association with cardiovascular disease, metabolic syndrome, type 2 diabetes, and hypertension, a complete assessment includes review of body mass index, blood pressure, and fasting glucose or HbA1c. Your dermatologist coordinates appropriate referrals to primary care or internal medicine when these screening parameters indicate elevated cardiovascular or metabolic risk. Mental health screening for depression and anxiety is also part of comprehensive psoriasis evaluation.

Laboratory Testing

Baseline laboratory work is obtained before initiating systemic therapy. This includes a complete blood count, comprehensive metabolic panel including liver and renal function tests, fasting lipid panel, hepatitis B and C serology, HIV screening when indicated, and tuberculosis testing before biologic therapy. These tests establish safety baselines, screen for conditions that influence medication selection, and guide monitoring protocols throughout treatment.

Skin Biopsy

Biopsy is rarely required for classic plaque psoriasis. When the diagnosis is genuinely uncertain, when a condition such as mycosis fungoides (cutaneous T-cell lymphoma) or secondary syphilis cannot be clinically excluded, or when a patient is not responding as expected to standard therapy, a punch biopsy provides tissue for histopathologic analysis. The characteristic findings include parakeratosis, an absent granular layer, regular epidermal ridge elongation, neutrophilic micro-abscesses, and dilated tortuous dermal capillaries.

Rosacea Treatment Options

There is no cure for rosacea. The goal of treatment is to control symptoms, suppress flares, prevent progression, and improve quality of life over the long term. Because rosacea is a chronic condition with a relapsing-remitting course, management is ongoing, not a single course of treatment with a defined endpoint.

The most effective approach matches treatment to subtype. What works for persistent erythema does not address papulopustules. What reduces telangiectasia requires a different modality than what manages ocular involvement. Here is what the evidence supports for each clinical presentation.

Trigger Identification and Avoidance

Identifying and consistently avoiding personal triggers is the single highest-impact, lowest-risk intervention available for rosacea. Common triggers include UV light exposure, heat, hot beverages, alcohol (particularly red wine), spicy foods, extreme cold, vigorous exercise, emotional stress, certain skincare products, and some medications that cause vasodilation. Your trigger profile is individual. A symptom diary kept over 4 to 6 weeks is the most practical tool for identifying your specific patterns.

No medication or procedure fully compensates for persistent trigger exposure. Trigger management is not optional. It is the foundation of every rosacea treatment plan.

Gentle Skin Care and Sun Protection

Daily broad-spectrum mineral sunscreen with SPF 30 or higher is non-negotiable in rosacea management. UV radiation is rosacea’s most consistent trigger and one of its strongest long-term drivers. Physical sunscreens containing zinc oxide or titanium dioxide are preferred for rosacea-prone skin because they sit on top of the skin rather than being absorbed, reducing the risk of irritation.

Twice-daily cleansing with a gentle, fragrance-free, soap-free cleanser and consistent application of a rosacea-appropriate moisturizer supports the skin barrier and reduces reactivity. Rosacea-prone skin is hypersensitive by nature. An overly complex or aggressive skincare routine worsens symptoms.

Topical Medications for Erythema and Flushing

For patients with persistent facial erythema as a dominant feature, two FDA-approved topical vasoconstrictors offer targeted redness reduction.

Brimonidine tartrate 0.33% gel (Mirvaso) is a selective alpha-2 adrenergic receptor agonist that constricts superficial blood vessels, reducing erythema within 30 minutes of application. Its effects last up to 12 hours. High-quality clinical evidence from Cochrane reviews shows that 50 percent of patients achieve a two-grade improvement in erythema severity versus 20 percent with placebo. Its main limitations include rebound erythema in some patients and the need for consistent daily application.

Oxymetazoline hydrochloride 1% cream (Rhofade) works through a complementary alpha-1 adrenergic mechanism, similarly reducing erythema for up to 12 hours. Both agents are applied once daily and are FDA-approved for adults 18 and older.

Topical Medications for Papules and Pustules

Three topical agents have FDA approval and robust clinical evidence for papulopustular rosacea.

Ivermectin 1% cream (Soolantra) is applied once daily and addresses both the inflammatory and Demodex-related components of papulopustular rosacea. Multiple high-quality randomized controlled trials confirm it is slightly more effective than metronidazole, with excellent tolerability. It is a first-line choice for moderate papulopustular disease.

Metronidazole 0.75% to 1% gel or cream (MetroGel, MetroCream, Noritate) is applied once or twice daily and has decades of clinical evidence supporting its efficacy in reducing inflammatory lesions and erythema. It remains a widely used first-line option and an effective maintenance therapy.

Azelaic acid 15% gel (Finacea) is applied twice daily and offers anti-inflammatory and mild antimicrobial properties. Its additional benefit of reducing post-inflammatory hyperpigmentation makes it particularly valuable for patients with darker skin tones who are prone to pigmentation changes following rosacea flares.

Oral Antibiotics

When topical therapy alone fails to control papulopustular rosacea, or when disease is moderate to severe, oral antibiotics provide systemic anti-inflammatory benefit.

Low-dose doxycycline 40 mg once daily (Oracea), a modified-release formulation with both immediate and delayed-release components, is the only oral agent FDA-approved specifically for rosacea. At this sub-antimicrobial dose, it exerts meaningful anti-inflammatory effects without contributing to antibiotic resistance. High-quality clinical evidence from Cochrane reviews confirms its efficacy with fewer adverse effects than higher-dose doxycycline formulations.

Standard doxycycline 50 to 100 mg twice daily and minocycline 50 to 100 mg twice daily are also prescribed for inflammatory rosacea, typically for 8 to 12 weeks. Oral antibiotics are always combined with topical therapy and never used indefinitely. Once disease is controlled, topical maintenance therapy continues to prevent relapse.

Oral Isotretinoin

Low-dose oral isotretinoin at 0.25 to 0.3 mg per kilogram daily is a powerful option for severe papulopustular rosacea and early phymatous disease that has not responded to antibiotics. High-quality clinical evidence supports its superiority over doxycycline 50 to 100 mg for inflammatory rosacea. A treatment course typically runs 12 to 16 weeks.

Unlike in acne, rosacea commonly relapses after isotretinoin discontinuation, so maintenance topical therapy is essential following the completion of a course. Isotretinoin carries significant side effects and requires careful monitoring, including baseline and periodic blood work and, for women of childbearing age, mandatory pregnancy prevention through the iPLEDGE program.

Laser and Light-Based Treatments

For established telangiectasia and persistent erythema that does not respond to topical vasoconstrictors, laser and light-based therapies are the most effective available interventions.

Pulsed dye laser (PDL) at 585 to 595 nanometers and intense pulsed light (IPL) therapy both target oxyhemoglobin in dilated blood vessels, selectively destroying abnormal vasculature while leaving surrounding tissue intact. Cochrane review evidence confirms that both modalities produce meaningful improvement in erythema and telangiectasia with comparable efficacy. Multiple sessions are typically required, spaced 4 to 6 weeks apart.

IPL also addresses diffuse redness with a broader treatment area, making it particularly suited to widespread erythematotelangiectatic presentations. For ocular rosacea, IPL performed by an experienced practitioner offers additional benefit for meibomian gland dysfunction and chronic dry eye associated with the condition.

Treating Phymatous Rosacea

Medical therapy addresses early phymatous disease. Low-dose doxycycline slows sebaceous gland hyperplasia, and low-dose isotretinoin reduces sebaceous gland size, potentially preventing further thickening. Neither agent, however, reverses existing tissue hypertrophy.

Established rhinophyma and other phymatous changes require procedural intervention. Ablative CO2 laser is the most widely used and evidence-supported modality for surgical debulking of rhinophyma, offering precise tissue removal with controlled depth and good cosmetic outcomes. Erbium laser, electrosurgery, radiofrequency ablation, and scalpel excision are alternative approaches. The choice depends on the degree of tissue involvement and the treating physician’s experience.

Managing Ocular Rosacea

Ocular rosacea requires a structured, stepwise approach. Mild disease responds to warm compresses applied twice daily, gentle eyelid hygiene, omega-3 fatty acid supplementation, and preservative-free artificial tears. These measures address meibomian gland dysfunction and reduce eyelid inflammation.

Moderate to severe ocular rosacea requires medical therapy. Topical cyclosporine 0.05% ophthalmic emulsion (Restasis) reduces inflammatory mediators in the tear film and is more effective than artificial tears alone for burning and light sensitivity. Low-dose doxycycline or oral antibiotics address the systemic inflammatory component driving eyelid and conjunctival disease. Patients with visual disturbance or significant corneal involvement are co-managed with an ophthalmologist.

Maintenance Treatment

Because rosacea is a chronic relapsing condition, maintenance therapy is not optional. Once symptoms are controlled, stepping down to a simplified maintenance regimen, typically a single topical agent combined with ongoing trigger avoidance and sun protection, sustains remission and prolongs the interval between flares. Discontinuing all treatment after a good response almost invariably leads to recurrence.

When Should You Get Psoriasis Evaluated?

You should see a dermatologist if you notice:

•         Persistent or recurring scaly plaques on the elbows, knees, scalp, or lower back
•         Nail pitting, oil spots, thickening, or separation from the nail bed
•         Joint pain, swelling, dactylitis, or Achilles tendon tenderness accompanying skin lesions
•         A sudden, widespread eruption of small plaques following a streptococcal infection
•         Rapidly spreading erythema covering large areas of the body
•         Sterile pustules on the palms, soles, or anywhere across the body
•         Skin disease significantly affecting your daily life, work, or mental health
•         Any skin condition previously diagnosed as psoriasis that is no longer responding to treatment

A professional evaluation confirms your diagnosis, determines its subtype and severity, screens for joint and systemic disease, and connects you with a treatment plan that reflects the full sophistication of modern psoriasis care.

Psoriasis Treatment Options

Psoriasis treatment has been transformed over the past two decades by a profound expansion in therapeutic options. From foundational topical therapy through targeted biologics that achieve near-complete skin clearance, the treatment landscape now offers genuinely life-changing options for patients who previously had few. Treatment selection depends on disease severity, affected body sites, presence of psoriatic arthritis, patient preferences, comorbidities, and prior treatment history.

Emollients and Skin Care

Consistent application of fragrance-free emollients and moisturizers is foundational in psoriasis management regardless of severity. Emollients reduce scale, minimize transepidermal water loss, soften plaques, and enhance the penetration of topical active agents applied afterward. They don’t treat the inflammation driving psoriasis but significantly reduce the mechanical and sensory burden of dry, scaling skin. Twice-daily application, particularly after bathing, is recommended for all patients.

Topical Corticosteroids

Topical corticosteroids are the first-line anti-inflammatory treatment for mild to moderate psoriasis and provide rapid, meaningful plaque reduction. The number needed to treat for 50 percent improvement at 4 weeks with moderate to high-potency agents is 3, reflecting strong clinical efficacy. Potency is selected based on body site: low-potency for the face, neck, and intertriginous areas; mid- to high-potency for thick, lichenified plaques on the trunk and extremities.

Proactive maintenance therapy, applying a topical corticosteroid twice weekly to areas prone to flaring even when skin appears clear, significantly reduces recurrence frequency and overall cumulative steroid exposure. Side effects including skin atrophy, striae, and telangiectasia are real but largely reversible with appropriate use under dermatologic oversight. Systemic corticosteroids are strongly contraindicated in psoriasis because withdrawal reliably triggers severe rebound flares or precipitates the dangerous pustular or erythrodermic forms.

Vitamin D Analogs

Calcipotriene and calcitriol normalize keratinocyte proliferation and differentiation by modulating intracellular signaling. Applied once or twice daily, they provide anti-inflammatory and anti-proliferative benefit through a mechanism entirely distinct from corticosteroids. The combination of calcipotriene and betamethasone dipropionate in a single ointment, gel, or foam formulation consistently outperforms either agent alone and is one of the most evidence-supported topical combinations in psoriasis care. A practical regimen uses vitamin D analogs on weekdays and the combination product on weekends to maximize efficacy while limiting steroid exposure.

Newer Topical Agents

Roflumilast, a topical phosphodiesterase-4 inhibitor available in cream and foam formulations, provides meaningful anti-inflammatory and antipruritic benefit. The cream formulation is particularly well-suited to the face and intertriginous areas where corticosteroid risks are highest. The foam formulation penetrates scalp and hirsute areas effectively.

Tapinarof 1% cream, a topical aryl hydrocarbon receptor agonist, is used as monotherapy or in combination with topical corticosteroids for mild to moderate psoriasis. It provides a glucocorticoid-sparing option for sensitive skin sites and is supported by strong efficacy evidence. Both agents are included in the 2025 AAD psoriasis guidelines with high-certainty evidence.

Tazarotene, a topical retinoid, is particularly effective for thick, chronic plaques on the trunk and extremities and for palmoplantar and nail psoriasis. It is most effective when combined with a topical corticosteroid, which also reduces the irritation it can cause.

Coal Tar and Salicylic Acid

Coal tar has anti-inflammatory and anti-proliferative properties and remains a useful adjunctive treatment, particularly for scalp psoriasis. It is applied at night and combined effectively with narrowband UVB light therapy in the Goeckerman regimen. Salicylic acid is a keratolytic that softens and removes scale, significantly improving the penetration of subsequently applied active agents. Concentrations of 2 to 6 percent are used in shampoos and leave-on preparations.

Phototherapy

Narrowband UVB phototherapy (311 to 313 nm) is the preferred phototherapeutic modality for moderate to severe psoriasis not controlled by topical therapy alone. Administered two to three times weekly, it reduces DNA synthesis in keratinocytes and induces mild immunosuppression within the skin without systemic immunosuppression. It is safe in children with significant body surface area involvement, and in pregnant and breastfeeding patients. Home-based phototherapy devices are as effective as office-based treatment and significantly reduce the treatment burden.

PUVA therapy, combining oral psoralen with UVA exposure, is more potent than narrowband UVB and produces remissions lasting several months in many patients. However, repeated PUVA exposure carries an established increased risk of squamous cell carcinoma, melanoma, and premature skin aging, limiting its use to patients for whom narrowband UVB is insufficient. The excimer laser delivers 308-nm UV light to focal, recalcitrant plaques without exposing surrounding normal skin.

Non-Biologic Systemic Agents

Systemic therapy is considered when body surface area involvement exceeds approximately 5 percent or when psoriasis significantly impacts quality of life despite topical therapy.

Methotrexate remains the most widely used non-biologic systemic agent worldwide and the most commonly prescribed systemic therapy in children. Administered once weekly at doses of 7.5 to 30 mg, it provides meaningful efficacy for plaque psoriasis, pustular psoriasis, and palmoplantar disease. Regular monitoring of CBC, liver, and renal function is required. Folic acid supplementation on non-methotrexate days reduces side effects without compromising efficacy.

Cyclosporine provides rapid, dramatic clearance for severe and recalcitrant psoriasis and is particularly valuable as a bridge therapy or for erythrodermic flares requiring urgent control. It is limited to courses of 12 to 16 weeks because of cumulative nephrotoxicity risk. Acitretin, an oral retinoid, is effective for severe plaque psoriasis, pustular psoriasis, and palmoplantar disease. It is teratogenic and must not be used in women of childbearing potential without strict contraception. Apremilast (Otezla), a PDE-4 inhibitor, provides modest systemic anti-inflammatory benefit without the immunosuppression or monitoring requirements of older agents and is FDA-approved for mild disease.

Deucravacitinib (Sotyktu), a selective TYK2 inhibitor, is an oral small molecule approved for moderate to severe plaque psoriasis that provides meaningful efficacy with a favorable side effect profile compared to JAK inhibitors.

Biologic Therapies

Biologic agents represent the most transformative therapeutic advance in psoriasis care. They target specific inflammatory cytokines and receptors with precision that produces levels of skin clearance previously unachievable with any treatment.

IL-17 Inhibitors: Secukinumab (Cosentyx), ixekizumab (Taltz), bimekizumab (Bimzelx), and brodalumab (Siliq) target IL-17A, IL-17A and IL-17F, or the IL-17 receptor, directly blocking the primary inflammatory pathway driving plaque psoriasis. They are among the fastest-acting and most effective biologics available. Ixekizumab and brodalumab show particularly rapid onset. IL-17 inhibitors are also highly effective for scalp and nail psoriasis.

IL-23 Inhibitors: Guselkumab (Tremfya), risankizumab (Skyrizi), tildrakizumab (Ilumya), and ustekinumab (Stelara, which targets both IL-12 and IL-23) block the p19 or p40 subunit of IL-23, upstream of the Th17 pathway. They offer durable, long-lasting responses with infrequent dosing schedules, making them practically appealing for patients who prefer less frequent injections.

TNF-alpha Inhibitors: Adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), and certolizumab pegol (Cimzia) have the longest clinical track record among psoriasis biologics and are also FDA-approved for psoriatic arthritis, making them particularly valuable when joint disease is present alongside skin disease.

Spesolimab (Spevigo), an IL-36 receptor inhibitor, is approved specifically for generalized pustular psoriasis, a previously undertreated and potentially life-threatening form of the disease.

All biologic therapies require baseline tuberculosis and hepatitis screening, completion of recommended vaccinations before initiation, and avoidance of live vaccines during treatment. Regular monitoring protocols are followed throughout treatment.

Treating Psoriatic Arthritis

Psoriatic arthritis requires systemic therapy to prevent joint destruction. TNF-alpha inhibitors including adalimumab and etanercept have the strongest evidence base for both skin and joint disease and are frequently the first-line systemic choice when psoriatic arthritis is the primary treatment driver. IL-17 inhibitors, IL-23 inhibitors, and JAK inhibitors also demonstrate significant benefit for joint disease. Methotrexate is used for mild to moderate psoriatic arthritis. Rheumatology co-management is essential for moderate to severe or structurally threatening joint disease.

Why Choose Connolly Dermatology for Psoriasis Treatment

Care Guided by Experience and Clinical Judgment

Managing psoriasis well demands far more than writing a prescription. It requires accurate subtype identification, objective severity assessment, systematic screening for psoriatic arthritis and systemic comorbidities, a treatment plan matched to the full complexity of your disease, and ongoing expertise to escalate therapy appropriately when earlier interventions are insufficient. Connolly Dermatology provides that depth of physician-led, evidence-guided care for every psoriasis patient.

Board-Certified Dermatologists

Our dermatologists are trained in the full spectrum of psoriasis presentations, from mild localized plaque psoriasis to erythrodermic and pustular emergencies and complex psoriatic arthritis presentations. Every treatment recommendation follows the most current American Academy of Dermatology guidelines and reflects the best available clinical evidence.

Comprehensive Diagnostic and Severity Assessment

We use validated scoring tools including PASI, BSA, PGA, and DLQI to objectively quantify your disease severity and track your treatment response over time. Every evaluation includes systematic psoriatic arthritis screening and assessment of cardiovascular and metabolic comorbidities. You receive care that accounts for the full systemic impact of your disease, not just the skin.

Access to the Full Treatment Spectrum

We offer every evidence-based treatment for psoriasis: optimized topical regimens, narrowband UVB phototherapy, methotrexate and other systemic agents, and the complete range of FDA-approved biologic therapies including IL-17, IL-23, and TNF-alpha inhibitors, oral small molecules, and targeted therapies for pustular psoriasis. If a more effective treatment exists for your specific situation, we’ll recommend it and help you access it.

Biologic Therapy Expertise

Biologic agents represent a paradigm shift in psoriasis care. Our dermatologists have extensive experience identifying appropriate biologic candidates, managing baseline screening and monitoring protocols, initiating therapy, and adjusting or switching agents when needed to optimize your response. For patients who have spent years with inadequately controlled psoriasis, biologic therapy can be genuinely life-changing.

Honest Communication About Outcomes

Psoriasis is a chronic disease. Management is a long-term partnership, not a single course of treatment. We set realistic expectations from the first visit, explain what each phase of your treatment will achieve, monitor your progress closely, and make adjustments based on your actual response. You’ll never feel dismissed or receive the same treatment indefinitely regardless of how your skin responds.

Patient Education and Support

Understanding your specific triggers, which treatments target which pathways, how to use topical agents correctly, and what warning signs suggest disease progression empowers you to manage your psoriasis more effectively between appointments. Clear, practical patient education is a priority at every visit.

Comfortable, Compassionate Care

The burden of living with psoriasis, the social self-consciousness, the chronic unpredictability, the joint pain, the daily treatment demands, is genuinely significant. Our team approaches every consultation with the empathy and respect that a disease with this degree of impact deserves.

What To Expect During Treatment

Guiding You Through Evaluation and the Next Steps

Starting psoriasis care with a dermatologist, particularly if previous treatment has been inadequate or inconsistent, can feel like both a relief and an adjustment. At Connolly Dermatology, we guide you through every stage of your evaluation and treatment so you know exactly what is happening with your skin and what to expect as your disease responds.

Before Your Appointment

Preparation helps your dermatologist build a complete clinical picture quickly. Note when your psoriasis first appeared, how it has evolved, and what your flare pattern looks like. Document every treatment you have tried, including products applied, dosages, and how your skin responded. Bring a list of all current medications, supplements, and any known allergies. Note any joint symptoms, family history of psoriasis or psoriatic arthritis, and significant recent stressors or illnesses that preceded flares. The more complete the picture you provide, the more precisely your evaluation and treatment plan can be tailored.

During the Evaluation

Your dermatologist reviews your history and performs a thorough skin examination. They assess the distribution, morphology, and severity of your plaques, examine the nails and scalp, and evaluate any flexural or palmoplantar involvement. Severity is graded using validated tools. Psoriatic arthritis screening is completed through targeted questions and, when indicated, joint examination.

Your dermatologist explains their findings clearly, identifies your psoriasis subtype, and discusses your treatment options in plain, practical language before anything is prescribed or initiated. Every component of the treatment plan is explained, including what it targets, how to use it, what to realistically expect, and over what timeframe. If biologic therapy is being considered, the full evaluation process, baseline screening, injection schedule, and monitoring requirements are explained during the same visit.

For patients with localized, treatment-resistant plaques, an intralesional corticosteroid injection can often be administered during the initial appointment for rapid lesion improvement.

After Your First Visit

Response timelines vary by treatment. Topical corticosteroids produce improvement within 2 to 4 weeks of consistent application. Vitamin D analogs take 6 to 8 weeks for full effect. Narrowband UVB shows progressive improvement over multiple sessions across 6 to 12 weeks. Biologics typically produce meaningful lesion reduction within 4 to 16 weeks depending on the specific agent. Patience and consistency are essential, and those expectations are established honestly from the start.

Follow-up appointments are scheduled to assess your treatment response using the same validated tools from your baseline evaluation, identify any side effects, and modify your plan based on what your skin is actually doing. If initial therapy is insufficient, we escalate appropriately rather than accepting a suboptimal outcome.

Once your psoriasis is well controlled, a maintenance plan sustains remission and minimizes flare frequency. Comorbidity monitoring continues at routine intervals. Joint symptoms are reassessed regularly. And as new treatments become available with stronger evidence, your plan evolves accordingly.

Get Clear Answers from Connolly Dermatology

Make Informed Decisions About Your Skin Health

Psoriasis is a chronic, immune-mediated systemic inflammatory disease driven by Th17 pathway dysregulation and abnormal keratinocyte proliferation. It has multiple distinct subtypes, each with specific treatment requirements. It is associated with psoriatic arthritis in up to 30 percent of patients and carries independently elevated risks of cardiovascular disease, metabolic syndrome, and significant psychological burden. And it is a condition that, without appropriate treatment, progresses.

Effective psoriasis management requires accurate subtype diagnosis, objective severity assessment, systematic screening for joint and systemic disease, a treatment plan that matches your specific disease profile, and ongoing expert oversight as your skin responds and your needs evolve. Topical therapy alone is insufficient for moderate to severe disease. Over-the-counter products are not a substitute for evidence-based dermatologic care.

If psoriasis is affecting your skin, your joints, or your quality of life, schedule a visit with Connolly Dermatology. Our board-certified dermatologists offer expert evaluation, comprehensive treatment planning, and the sustained clinical partnership needed to bring your psoriasis under real, lasting control.

Schedule a visit with a dermatologist to get clear, informed guidance about your skin.