Complete skin clearance refers to clearing all evidence of psoriasis from the skin. For people diagnosed with psoriasis, achieving complete skin clearance is the goal of treatment. While new treatments have made complete skin clearance possible for the first time, it may take some time to achieve. Additionally, no psoriasis treatments result in total skin clearance for 100 percent of the people who try them. Because of this, it’s important to keep in mind that complete skin clearance may not be possible for everyone diagnosed with psoriasis — but the goal should be to clear the skin as near to completely as possible.
People with psoriasis who achieve complete skin clearance no longer have bumpy, red or purple patches of skin that itch, hurt, crack, and bleed. While they may still have other psoriasis symptoms, receiving complete skin clearance indicates that the evidence of the condition on the skin is gone.
In an interview with Dermatology Times, Dr. Alice Gottlieb — clinical professor of dermatology at Icahn School of Medicine at Mount Sinai — said complete skin clearance means people with psoriasis “can run around naked and no one will know they have psoriasis.” It also means they don’t have the itching, burning, cracking, or bleeding skin characteristic of psoriasis and no longer require topical treatments to manage these symptoms. Typically, people with psoriasis need to stay on medication to remain clear. These medications do not cure psoriasis, but they can suppress it.
The severity of a person’s psoriasis is generally measured using either the Psoriasis Area and Severity Index (PASI) or the Physician Global Assessment (PGA). PASI is based on severity and the amount of body surface area, known as BSA, that is affected.
A PASI score under five is considered mild disease and a score over 10 is considered severe disease. The maximum PASI score is 72.
PGA is a six-point scale that assesses severity but doesn’t specifically assess body surface area. A PGA score of zero is clear skin while a score of four or higher is considered severe.
Many clinical trials measure the change in PASI scores to assess the effectiveness of a drug. In this context, a PASI score of 75 indicates a 75 percent reduction in a person’s starting PASI score. PASI 100 would indicate 100 percent reduction, or complete skin clearance.
These perfect scores may not be achievable for everyone diagnosed with psoriasis. Because of this, it is a good idea to discuss the topic with your dermatologist. The two of you can work together to determine whether complete skin clearance is a realistic goal for you.
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The medications used to achieve complete skin clearance in some people are called biologics. Biologics are bioengineered proteins that work by targeting specific cells or molecules of the immune system involved in inflammatory processes. There are several biologic medications on the market, and it can take some time to determine which one would work best for you without causing negative side effects.
The effectiveness of biologic medications is not 100 percent. One study of 846 people with psoriasis who tried biologics reported that approximately 25 percent achieved complete skin clearance after six months of treatment. Another study found complete skin clearance in 30 percent to 45 percent of participants who tried biologics.
When biologics first became available to treat psoriasis nearly 20 years ago, 75 percent skin clearance was hailed as a great success. Newer biologics coming out today can achieve skin clearance for many people. The expectation of 90 percent clearance with the newer biologics is realistic.
However, complete skin clearance may not be a realistic treatment response or end point for everyone with a diagnosis of psoriasis. A few key factors seem to influence the effectiveness of biologic treatment, including the choice of biologic, the severity of psoriasis before treatment, and the weight and overall health of the person seeking treatment.
Disease severity can affect how likely a person is to achieve complete skin clearance. One study of 515 people with psoriasis found that people with severe disease saw greater changes in their PASI score when treated with biologics, up to a certain level of severity. Few individuals with a starting PASI score of 30 or above achieved complete skin clearance. While few people with extremely severe psoriasis achieved complete skin clearance on biologics in this study, all participants reported improved quality of life.
At times, more severe skin psoriasis will be associated with psoriatic arthritis, so be sure to tell your dermatologist about any joint pain you have. Not all biologics for psoriasis treat the joints well.
Even if biologics do work for you, it may take some time to find the one that will help you achieve clear skin. Because there is no test that can tell which biologic will work best for you and because your medical insurance may not cover all of the biologics available, this process can take a while. If the particular medication you want to try is still in clinical trials, you may need to qualify for that trial to access it.
When you try a new biologic, you can expect to wait one to four months to experience maximal effectiveness. Additionally, biologics may become less effective over time, perhaps due to the body making antibodies against the treatment. Even if you do achieve complete skin clearance, it may not be possible to maintain it forever.
With some biologics, you may need to change to a different drug within five years. However, some of the newer biologics are proving to have sustained durability with at least five years of consistent results. There are more than a dozen biologics currently approved to treat psoriasis, so there are multiple options if a medication does not work for you or stops working over time.
Biologics are systemic medications given via injection or IV infusion. Some can be self-administered at home, but others require visits to a clinic or doctor’s office for an infusion every few weeks. These appointments can take some time, and some people do not feel well for a few days afterward. It may take several weeks for you to notice any major improvement in your psoriasis. The biologics differ in the frequency of injections, so talk to your dermatologist about which medicine fits best with your lifestyle.
A review of studies assessing the impact of weight on biologic effectiveness found that some biologics performed less well for people with higher body weight. If you have a higher body weight, talk to your dermatologist about which biologics can be adjusted for weight and which have proven results for people regardless of body weight.
Because they change the way the immune system works, biologics can increase your risk of contracting an infection and may make it harder for your body to fight infections after you get them. People who have previously tested positive for certain infections, like hepatitis B or tuberculosis, may not be able to take biologic medications. The newest biologics are much more specific in their suppression of the immune system, and the risk for infections is lower. You may need a tuberculosis test before beginning a biologic.
In addition, some people may experience itchiness and redness on the skin or at the injection site, especially when the biologic medication is given.
Recent research suggests that biologics do not increase the chance of contracting COVID-19, nor do they affect the efficacy of the COVID-19 vaccines.
It’s important to talk to your dermatologist about setting goals for treatment of psoriasis. They know the specifics of your health history and your psoriasis, so they can help you make informed decisions about treatment goals and medication options. Be sure to tell your dermatologist about any symptoms you experience beyond the skin, such as joint pain or gastrointestinal issues like inflammatory bowel disease.
On MyPsoriasisTeam, the social network and online support group for those living with psoriasis, more than 108,000 members talk about a range of personal experiences. Setting treatment goals and taking biologics to treat psoriasis are two of the most popular topics.
Are you wondering if complete skin clearance is possible for you? Are you considering biologics? Share your questions or experiences in the comments below or by posting on MyPsoriasisTeam.