For people living with moderate to severe psoriasis and psoriatic arthritis (PsA), biologics can be an effective alternative to traditional treatments like oral medications (taken by mouth), topicals (applied to the surface of the skin), or phototherapy. These injectable drugs offer many benefits, including the convenience of not having to take pills or apply topical medication daily. But, as with other psoriasis treatments, injectable biologics sometimes cause side effects — including, for some people, painful or burning sensations at the injection site.
“So, I started my first Taltz injections two weeks ago, and believe it or not, I feel maybe 15 percent better. I’m surprised,” wrote a MyPsoriasisTeam member. “I have to do the injection today. Boy, that burns so bad, though.”
In this article, we’ll look at why some people experience pain from injectable biologics, and we’ll suggest techniques to help bring relief.
Biologic drugs are typically used for moderate to severe psoriasis and PsA. Doctors may recommend biologics when topical treatments, phototherapy, and other types of systemic therapy (medication that affects your whole body) don’t control symptoms adequately.
Psoriasis and PsA are caused by an overactive immune system. Biologics target parts of the immune system and block the effects of excess cytokines, proteins that are often responsible for flare-ups. These inflammatory cytokines include tumor necrosis factor-alpha (TNF-alpha) and interleukins 12, 17, and 23.
Biologics need to be administered via injection or by intravenous (through a vein) infusion. This is because they consist of large molecules that can’t be properly absorbed when taken orally. Additionally, the compounds are complex and fragile, making them unstable in the gastrointestinal system.
Biologics can be administered in a clinical setting (a hospital, outpatient clinic, or facility). Those that can be absorbed subcutaneously (under the skin) can also be self-injected at home.
Some common biologics used to treat psoriasis include:
Learn more about biologics for psoriasis.
In general, biologics for psoriasis are considered safe and are generally well tolerated. They also offer a level of convenience. Instead of taking medications or applying creams daily, you can have an injection once every week, two weeks, or once a month — either at a clinic or in your own home — depending on the drug.
However, like any treatment, biologics have potential drawbacks, including side effects such as headache, nausea, and an increased risk of infection. Injections can also cause pain at the spot where the shot is administered.
Pain associated with biologic injections varies from person to person. Experiences among MyPsoriasisTeam members are all different. For some, injections are virtually painless. “There was no pain — I barely even felt the injection,” shared one member. “The first was in my thigh, and the second one I did in my stomach, near my belly button. But, no residual pain even.”
For others, the pain can be intense — but worth the benefits. “Had such a good few days,” wrote another member. “Injection done for two more weeks. The injections hurt, but well worth the pain lol ☺️.”
Still others find the pain unbearable: “Today, after only four injections, I’ve found out that I have to stop using Enbrel. I’m having a bad injection site reaction, and it’s painful.”
Researchers have identified several factors that can contribute to how much pain a person may experience, if any.
According to a study in Rheumatology and Therapy, contributing factors include:
Understanding the three main types of self-injection devices can be helpful, as some can cause more pain than others. Types of devices include:
Although some factors contributing to site pain may be beyond your control, you can try various techniques to reduce pain associated with injecting biologics.
To maintain the potency of your biologics, make sure to keep them chilled. You should read the product label or speak with your pharmacist to find out the proper temperature, but the standard is somewhere between 35.6 degrees to 46.4 degrees Fahrenheit (2 degrees and 8 degrees Celsius).
Fortunately, you don’t need to inject the biologics at a chilled temperature, which can cause pain. Generally, 30 to 45 minutes is enough time to safely let your biologics reach room temperature — don’t use any direct heat sources to speed up the process.
Speak with your health care provider or pharmacist, or read the medication’s warning label, to determine how long you can keep your particular medication out of the cold.
Icing the injection site before or after the shot may reduce some of the pain. “Try using an ice pack first on the area you’re going to do the injection,” one MyPsoriasisTeam member recommended.
You may also consider applying an over-the-counter topical analgesic, such as lidocaine cream, both before and five minutes after an injection.
Technique matters when you (or a caregiver) administer your injection — including the angle of the needle — and can affect whether you experience pain. Make sure a doctor or nurse demonstrates how to give yourself your shot. One study from Dermatology Times found that people performed self-injection better and were more satisfied when they had training and education materials.
For a prefilled syringe, researchers recommend orienting the device at a 45-degree or 90-degree angle and using a skin-pinch technique. This method entails pinching a 2 inch fold of skin between your thumb and index finger, according to Johns Hopkins. Make sure the skin covers the needle completely.
For an autoinjector, administer the shot at a 90-degree angle to the skin.
Depending on which biologic you take, injecting it at a slower rate may reduce injection-site pain. In one study, researchers found injecting a dose of heparin over a 30-second period led to less injection-site pain compared with injections lasting 10 seconds. Another study found that injecting a relatively viscous (thick) placebo (a substance designed to look like the treatment being studied but without any active ingredients) caused less pain when administered over 10 minutes instead of just one minute.
Importantly, studies have been inconclusive as to whether injecting a medication slowly will consistently result in less pain. The particular drug’s viscosity may also play a significant role.
It’s important to select the proper sites for subcutaneous injections. These areas should have a layer of fat between the skin and the muscle. Parts of the body with these layers include the:
Researchers report that injections in the thigh are more painful than those in the abdomen. “I find that doing them in the stomach doesn’t cause me any discomfort or bruising,” one MyPsoriasisTeam member shared.
To reduce irritation and pain, rotate among sites from injection to injection. “I rotate between my stomach and thighs. The thighs sting more,” shared another member.
As many as 20 percent of people have some level of injection anxiety, which could come from factors such as a fear of needles or a lack of confidence in their ability to self-administer. Some people anticipate a shot will be painful, which can influence how much pain they experience.
Cedars-Sinai recommends relaxation techniques, such as deep breathing or visualization, to help reduce shot-related anxiety. According to a couple of other small studies in The Clinical Journal of Pain, coughing twice (without moving your arms) or inhaling deeply and then holding your breath while you get your shot may help.
Learn more about overcoming fear of self-injections for psoriasis.
As noted, technique matters when injecting biologics. Symptoms from PsA (such as joint pain) or other conditions (such as shaking or vision problems) can make it difficult to use the best techniques when giving yourself a shot.
This may be less of an issue if you use self-injection pens because they don’t require as much finger dexterity. The problem with self-injection pens, though, is that they’re more likely to cause swelling, bruising, or pain — in part because you can’t control how quickly you administer the drug.
Regardless of what injection device you have, consider asking a friend or loved one for help. Alternatively, you could go to a clinic where a health care professional can administer the shot, although this approach can be costlier and more time-consuming.
If you’re experiencing intolerable injection-related pain, your doctor may be able to help.
Other options your doctor might consider include prescribing an entirely different biologic or a different formulation of your current biologic. Drug companies in recent years have released versions of biologics free of a chemical called citrate. The chemical helps drugs maintain their stability but has been linked to injection-related pain. Versions of citrate-free biologics approved by the U.S. Food and Drug Administration (FDA) include Taltz and Humira, and they’re as clinically effective as the original formulations.
MyPsoriasisTeam is the social network for people with psoriasis and psoriatic arthritis. On MyPsoriasisTeam, more than 115,000 members come together to ask questions, give advice, and share their stories with others who understand life with psoriasis and psoriatic arthritis.
Are you taking prescribed injectable psoriasis medications? Do you follow any strategies to minimize injection-related pain? Share your experience in the comments below, or start a conversation on MyPsoriasisTeam.