Psoriasis is a disease of the skin that is characterized primarily by the presence of red, itchy, elevated plaques, on the skin, usually covered by silver-colored or white scales. There are some areas of the body where you see it more often, such as the elbows, knees, scalp, belly button, and buttocks, but psoriasis can appear anywhere on the body. Nowadays, the goal of treatment is patient satisfaction. Some patients want to be 100% free of disease; other patients vary in the amount of psoriasis that they tolerate. As a dermatologist, I have to take into account what the patient wants in terms of treatment. Some patients don’t want injections or other systemic treatments and prefer the use of topicals. Some patients cannot tolerate very mild psoriasis, while I have patients with severe psoriasis that doesn’t bother them. So it depends a lot on the patient, but when both the doctor and the patient decide together that the medicine that they’re receiving is not working out for whatever reason, that’s the time to move on. Typically, we decide to try something new if we notice the following red flags: You’ve given the treatment enough time to work—but nothing has changed. Sometimes, patients expect medication to kick in immediately and are concerned it’s not working when they don’t see instant results. I tell my patients that it’s important for them to give their treatment enough time to work. How long it takes for a medication to be effective depends on the type of treatment and the individual patient. I try to stress that it can take 2 to 3 months for phototherapy, or light therapy, to have a noticeable impact. With biologics, a type of systemic treatment, it can take between 4 to 6 weeks. But if you’ve given the treatment enough time to really have an impact and your psoriasis is still not improving, it’s definitely time to move to another treatment. You’re having trouble adhering to your treatment regimen. With psoriasis patients, adherence is more difficult with topicals, which makes sense: topicals can be messy, sticky, and a hassle to apply. I’ve found that many of my patients particularly dislike ointments, since they’re more visible on the skin and can cause clothes to stick to the body. Creams are less effective but are a bit easier to manage, so when patients tell me they’re having trouble, I might prescribe a cream to wear during the day and an ointment to wear at night. If you’re having difficulty following your treatment instructions, talk to your doctor about other options. Nowadays, there are a lot of choices out there. You can’t tolerate the side effects. Sometimes, side effects cause patients to want to switch. For example, if a patient is on methotrexate and their liver enzymes rise significantly, then they’ve got to stop and switch to something else. If they’re using topical creams, ointments, or steroids and they start to have atrophy of the skin, then it’s time to move on. Because biologics tend to suppress the immune system, patients are at a higher risk of developing infections while taking them. Because of this side effect, I’m especially careful when treating older patients, because their immune systems are weaker due to their age. If you’re on a biologic and are worried about your risk of contracting infections, it may be time to discuss other treatments with your doctor. Your treatment is just not working. Sometimes, a medication that worked fine for a period of time loses effectiveness or stops working altogether. This can occur with topical steroids, when your cells become resistant to them and they’re no longer effective. Depending on the situation, if you stop applying the steroids for a while, they may begin working again after a while. It’s common that biologics stop working over time. After a while, patients may develop antibodies that fight the biologic, rendering it ineffective. Often, my patients will start a new biologic and find success, but then after about two years, it might stop working and it’s time to switch to something new. It’s quite common to cycle through biologics over the years as they lose effectiveness. However, the field of biologics is exploding, and the newest ones have fewer side effects and are much more targeted. I think that very soon we’ll have better medicines that will offer much more sustained relief from psoriasis. Talk to Your Doctor The important thing to remember is that psoriasis can be effectively treated, so if you’re not happy with the results of one option, another may be better for you. If your psoriasis treatment is not right for you, discuss next steps with your physician.