Psoriasis clinical guideline

1. Psoriasis is a chronic, multisystem, inflammatory disease that affects approximately 3 percent of the world’s population, with most patients presenting mild to moderate disease. Many of these cases can be successfully treated with topical agents, therefore, appropriate management with topical therapies is a crucial skill healthcare providers should acquire in order to benefit patients and reduce healthcare costs.

2. Psoriasis may be triggered or exacerbated by infections, physiological, emotional and environmental stressors, withdrawal of systemic corticosteroids, alcohol consumption, smoking, as well as cutaneous trauma.

3. This guideline addresses the management of psoriasis with topical therapies, alterative and complementary medicine and the tools to assess psoriasis severity.

4. Topical corticosteroids are recommended for the treatment of plaque psoriasis not involving intertriginous areas. The use of topical corticosteroids for > 12 weeks can be considered if done under careful supervision of a physician.

5. Steroid sparing agents such as vitamin D analogs, tazarotene and calcineurin inhibitors alone or in combination with steroids can be used to treat psoriasis with lower risk of steroid induced adverse effects. The alternate use of steroids and steroid sparing agents play a critical role in chronic management of psoriasis.

6. Other topical agents like emollients, salicylic acid, anthralin and coal tar can be also used alone or in combination with topical steroids for the treatment of psoriasis

7. Topical treatments can be combined with biologic and other systemic agents to increase the efficacy of therapy.

8. Severity measurement of psoriasis can be performed with different tools. While BSA, PGA, BSA x PGA can be used in clinical practice, PASI is a tool recommended for clinical trials and not for clinical practice. Additionally, subjective symptoms and quality of life assessment tools such as DLQI, PSI and pruritus assessment can provide useful information about the patient’s quality of life.

9. The alternative medicine section assessed the available evidence on the treatment of psoriasis with traditional Chinese medicine, herbal therapies (Aloe Vera and St. John’s Wort), diet/dietary supplements (Fish oil, vitamin D, turmeric/curcumin, zinc, gluten-free diet) and mind/body interventions (Hypnosis, stress reduction/meditation). Due to the lack of evidence or conflicting evidence among studies this guideline presents the available information but does not provide a recommendation about the use of these agents for the treatment of psoriasis.

The guideline covers clinical questions about the efficacy and safety of 12 oral-systemic, non-biologic medications.

Methotrexate is recommended for the treatment of moderate to severe psoriasis in adults and is less effective than adalimumab and infliximab for cutaneous psoriasis. The current guideline also provides revised monitoring guidance for methotrexate associated hepatotoxicity recommending new non-invasive tests to evaluate for hepatic fibrosis.

Apremilast is recommended for the treatment of moderate to severe psoriasis in adults.

Cyclosporine is recommended for patients with severe, recalcitrant psoriasis. It can also be used for the treatment of erythrodermic, generalized pustular psoriasis and/ or palmoplantar psoriasis.

Acitretin is recommended as a monotherapy or as a combination therapy with PUVA or UVB. Acitretin should not be used in patients who are pregnant or intend to become pregnant or nursing.

Other non-biologics that are discussed in the guideline for the treatment of psoriasis but are not FDA approved for that indication include: tofacitinib, hydroxyurea, mycophenolate mofetil, azathioprine, leflunomide, tacrolimus, and thioguanine. Fumaric acid esters are approved in the United States for treatment of relapsing forms of multiple sclerosis and can be considered for psoriasis.

1. Psoriasis is a chronic, multisystem, inflammatory disease that affects approximately one percent of children, with onset most common during adolescence. One-third of psoriasis cases begin in the pediatric years.

2. Psoriasis may be triggered or exacerbated by infections, physiological, emotional and environmental stressors, as well as cutaneous trauma. Pediatric psoriasis in particular can be associated with emotional stress, increased body mass index, second-hand cigarette smoke, pharyngeal and perianal Group A beta-hemolytic strep infection, Kawasaki disease, withdrawal of systemic corticosteroids.

3. This guideline addresses the assessment and management of major comorbid conditions associated with psoriasis, including psoriatic arthritis, metabolic syndrome, cardiovascular disease, dyslipidemia, hypertension, insulin resistance, mental health and Inflammatory bowel disease.

4. Identification of comorbidities requires the attention of the patient’s primary care provider and may have an important impact on management decisions for psoriasis as a cutaneous disease.

5. Topical corticosteroids with Vitamin D are commonly used as an off label treatment for pediatric psoriasis. However, caution should be used regarding ultra-high and high potency corticosteroids. Topical tazarotene is used in combination with topical corticosteroids for skin or nail psoriasis. Psoriasis treatment of the face and genitalia is effective with off-label topical calcineurin inhibitors either as monotherapy or in combination with topical corticosteroids.

6. Side effects of Anthralin may limit its use and should not be used for face or genitalia. However, it is effective as a long-term treatment of mild to moderate disease.

7. Phototherapy is effective for moderate to severe plaque as well as guttate psoriasis and is often used in conjunction with anthralin or coal tar as adjuvants.

8. Among non-biologic systemic drugs, methotrexate is most commonly used for moderate to severe psoriasis with good efficacy and should be supplemented with folic acid. Cyclosporine is effective for moderate to severe pediatric psoriasis particularly for patients with pustular or erythrodermic psoriasis. While systemic retinoids are effective for guttate psoriasis, pustular and palmar planter psoriasis, it does not cause immunosuppression and can be helpful for transplant patients.

9. Etanercept and Ustekinumab are FDA approved for four years and older and twelve years and older respectively. Other biologic drugs are used off-label. Biologics can be used in combination with systemic and topical therapies.

This guideline addresses multiple phototherapy treatment options ranging from widely used ultraviolet modalities to the combined use of photosensitizing agents to newer and less prevalent choices, which have demonstrated promise. The recommended dosing regimen, efficacy, and adverse effects of the various phototherapy modalities used as monotherapy or in combination with other psoriasis therapies to treat moderate-to-severe psoriasis in adults was assessed for each of the following phototherapy treatments:

• Narrowband UVB

• Broadband UVB

• Targeted UVB

  • Excimer laser

  • Excimer light

  • Targeted narrowband UVB light

• UVA with psoralens (PUVA)

  • Topical

  • Oral

  • Bath

• Photodynamic therapy

• Grenz ray

• Climatotherapy

• Visible light

• Goeckerman therapy (not a form of phototherapy)

• Pulsed dye laser (PDL)

A prior guideline was last published in 2009. This 2019 update provides significant additional scope including:

• Evidence-based use of phototherapy in different types of psoriasis

• Evidence-based use of phototherapy in combination with other treatment modalities

• New modalities and specific applications identified within the past decade

• Safety data including:

  • Adverse events

  • Contraindications

  • Pregnancy and lactation

  • Risk of malignancy

• Role of the dermatologist: Identifying those patients in whom phototherapy may be a viable or preferred treatment option, either as monotherapy or an adjunct, and working with the patient to outline risks and benefits and to make a joint decision on the best modality and dosing schedule.

• Role of patient preferences addresses the need of openly discussing safety and efficacy factors that may have an impact on patient decision to start certain treatments.

• Patient education referring to the importance of educating psoriasis patients regarding etiology, comorbidities and treatment options associated with psoriasis were discussed .

Related Academy resources

• Clinical guideline flowchart for treating psoriasis patients using phototherapy (PDF)

• Supplementary tables for treating psoriasis patients using phototherapy (PDF)

• Psoriasis is a chronic, inflammatory, multisystem disease which affects up to 3.2% of the US population.

• Based on current evidence, this guideline addresses important clinical questions regarding biologic agents used as monotherapy or in combination with other psoriasis therapies to treat moderate to severe psoriasis in adults, emphasizing treatment recommendations.

• The guideline assesses the efficacy, effectiveness, effect of switching and adverse effects of all biologic agents that have been approved by the Food and Drug Administration (FDA) for the treatment of psoriasis or are currently undergoing the FDA approval process:

  • TNF inhibition

    • etanercept (FDA approval 04/30/2004)

    • infliximab (FDA approval 09/27/2006)

    • adalimumab (FDA approval 01/22/2008)

    • certolizumab (FDA approval 05/27/2018)

  • IL-12/IL-23 inhibition

    • ustekinumab (FDA approval 09/25/2009)

  • IL-17 inhibition

    • secukinumab (FDA approval 01/21/2015)

    • ixekizumab (FDA approval 03/22/2016)

    • brodalumab (FDA approval 02/15/2017)

  • IL-23 inhibition

    • guselkumab (FDA approval 07/13/2017)

    • tildrakizumab (FDA approval 03/21/2018)

    • risankizumab (FDA approval pending)

• This guideline also highlights the need to educate patients regarding the etiology, comorbidities, and treatment options associated with psoriasis, as well as the dermatologist’s role in monitoring patients and educating them regarding the risks and benefits associated with biologic agents.

• The guideline emphasizes the need for dermatologists to be up-to-date regarding biologic safety information, as well as the importance of multidisciplinary care to improve outcomes for patients.

Related Academy resources

• Clinical guideline flowchart for treating psoriasis patients using biologics (PDF)

• Supplementary table for treating psoriasis patients using biologics (PDF)

• Psoriasis is a chronic, inflammatory, multisystem disease which affects up to 3.2% of the US population.

• Psoriasis is associated with several comorbidities, many of which first manifest as skin disease.

• This guideline addresses the assessment and management of major comorbid conditions associated with psoriasis, including arthritis, heart disease, metabolic syndrome, smoking, excessive alcohol intake, inflammatory bowel disease, and psychiatric disorders.

• Identification of comorbidities may require the attention of the patient’s primary care provider and may impact management decisions for cutaneous disease.

• The guideline also highlights the dermatologist’s role in identifying comorbidities by screening for them and/or alerting psoriasis patients’ primary care physicians about these associations.

Related Academy resources

• Clinical guideline flowchart for assessing comorbidities in patients with psoriasis (PDF)

Dermatology World articles

• Taking aim at psoriasis: Experts worldwide embrace treat-to-target 

• What advice should dermatologists give psoriasis patients about CV risk? 

MIPS reporting

• MIPS quality measures

Academy position statements

• Guidance Statement on Documentation of Patient Encounters and Procedures (PDF download)

• Cost-Effective Dermatologic Care (PDF download)

• Maintenance Therapy for Psoriasis Patients (PDF download)

• Patient Access to Affordable Treatments (PDF download)

• Pharmaceutical Compounding (PDF download)

• Treatment of Psoriatic Patients (PDF download)

Patient pamphlet

• Psoriasis and Psoriatic Arthritis Pamphlet 

Simulated Patient Encounter

• Simulated Patient Encounter - Medication Management