Management and Treatment of Psoriasis with Biologics

Publication Date: February 1, 2019
Last Updated: March 14, 2022

Recommendations

 TNF-α inhibitor etanercept

Etanercept is recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis. (A)
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The recommended starting dose of etanercept is 50 mg taken as a selfadministered subcutaneous injection twice weekly for 12 consecutive wk. (A)
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The recommended maintenance dose of etanercept after the initial 12 wk is 50 mg once weekly. Etanercept administered at a dose of 50 mg twice weekly is more efficacious than a dose of 50 mg once weekly and may be required for better disease control in some patients. (A)
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Etanercept is recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis affecting the scalp. (A)
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Etanercept is recommended as a monotherapy treatment option for use in adult patients with moderate-to-severe plaque psoriasis affecting the nails. (A)
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Etanercept can be recommended as a monotherapy treatment option for use in adult patients with other subtypes (pustular or erythrodermic) of moderate-to-severe plaque psoriasis. (B)
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Etanercept is recommended as a monotherapy treatment option in adult patients with plaque psoriasis of any severity when associated with significant psoriatic arthritis. (A)
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Combination of etanercept and topicals, such as high-potency corticosteroids with or without a vitamin D analogue, is recommended as a treatment option to augment efficacy for the treatment of moderate-tosevere plaque psoriasis. (A)
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Etanercept may be combined with acitretin to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults. (B)
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Combination of etanercept and methotrexate is recommended as a treatment option to augment efficacy for the treatment of moderate-tosevere plaque psoriasis in adults. (B)
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Etanercept may be combined with apremilast to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults. (C)
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Etanercept may be combined with cyclosporine to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults when clinically indicated. (C)
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Etanercept may be combined with narrowband ultraviolet phototherapy to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults. (B)
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TNF-α inhibitor infliximab

Infliximab is recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis. (A)
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The recommended starting dose of infliximab is an infusion of 5 mg/kg administered at wk 0, wk 2, and wk 6, and thereafter it is administered every 8 wks. (A)
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Infliximab is recommended to be administered at a more frequent interval (less than every 8 weeks and as frequently as every 4 weeks during the maintenance phase) and/or at a higher dose up to 10 mg/kg for better disease control in some adult patients. (B)
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Infliximab can be recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis affecting the palms and soles (plaque-type palmoplantar psoriasis). (B)
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Infliximab can be recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis affecting the nails. (B)
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Infliximab can be recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis affecting the scalp. (B)
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Infliximab may be recommended as a monotherapy treatment option in adult patients with other subtypes (pustular or erythrodermic) of moderate-tosevere plaque psoriasis. (C)
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Infliximab is recommended as a monotherapy treatment option in adult patients with plaque psoriasis of any severity when associated with significant psoriatic arthritis. Infliximab also inhibits radiographically detected damage of joints in patients with psoriatic arthritis. (A)
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Combination of infliximab and topicals such as high-potency corticosteroids with or without a vitamin D analogue can be recommended as a treatment option to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults. (B)
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Infliximab may be combined with acitretin to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults. (C)
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Infliximab may be combined with methotrexate to possibly augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults. (B)
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Infliximab may be combined with apremilast to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults when clinically indicated. (C)
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TNF-α inhibitor adalimumab

Adalimumab is recommended as a monotherapy treatment option for adult patients with moderate-to-severe plaque psoriasis. (A)
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Adalimumab is recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis affecting the nails. (A)
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The recommended starting dose of adalimumab is 80 mg taken as 2 self-administered subcutaneous 40-mg injections of the initial dose, followed by a 40-mg selfadministered subcutaneous injection 1 wk later, followed by 40 mg self-administered every 2 wk thereafter. (A)
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A maintenance dose of adalimumab 40 mg/wk is recommended for better disease control in some patients. (A)
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Adalimumab is recommended as a monotherapy treatment option for adult patients with moderate-to-severe plaque psoriasis affecting the palms and soles (palmoplantar psoriasis). (A)
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Adalimumab can be recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis affecting the scalp. (B)
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Adalimumab can be recommended as a monotherapy treatment option in adult patients with other subtypes (pustular or erythrodermic) of moderate-to-severe psoriasis. (B)
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Adalimumab is recommended as a monotherapy treatment option in adult patients with plaque psoriasis of any severity when associated with psoriatic arthritis. (A)
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Combination of adalimumab and topicals such as high-potency corticosteroids with or without a vitamin D analogue can be recommended as a treatment option to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults. (B)
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Adalimumab may be combined with acitretin to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults. (C)
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Adalimumab may be combined with methotrexate to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults. (B)
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Adalimumab may be combined with apremilast to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults. (C)
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Adalimumab may be combined with cyclosporine to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults. (C)
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Adalimumab may be combined with narrowband ultraviolet phototherapy to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults. (B)
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IL-12/IL-23 antagonist ustekinumab

Ustekinumab is recommended as a monotherapy treatment option for use in adult patients with moderate-to-severe plaque psoriasis. (A)
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The recommended starting doses of ustekinumab are as follows:
(a) For patients weighing ≤100 kg, 45 mg administered subcutaneously initially and 4 wk later, followed by 45 mg administered subcutaneously every 12 wk
(b) For patients weighing >100 kg, 90 mg administered subcutaneously initially and 4 wk later, followed by 90 mg administered subcutaneously every 12 wk.
(A)
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The recommended alternate dosage for ustekinumab is administered at higher doses (90 mg instead of 45 mg in patients weighing $100 kg) or at a greater frequency of injection (eg, every 8 wk in its maintenance phase) for those with an inadequate response to standard dosing. (A)
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Ustekinumab can be used as monotherapy for adult patients with moderate-to-severe plaque psoriasis affecting the palms and soles (plaque type palmoplantar psoriasis). (B)
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Ustekinumab can be recommended as a monotherapy treatment option for use in adult patients with moderate-to-severe plaque psoriasis affecting the nails. (B)
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Ustekinumab can be used as monotherapy for use in adult patients with moderate-tosevere plaque psoriasis affecting the scalp. (C)
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Ustekinumab can be used as monotherapy for use in adult patients with other subtypes (palmoplantar, pustular, or erythrodermic) of moderate-to-severe plaque psoriasis. There is limited evidence for its use in inverse and guttate psoriasis. (C)
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Ustekinumab is recommended as a monotherapy treatment option for use in adult patients with plaque psoriasis of any severity when associated with psoriatic arthritis. (A)
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Combination of ustekinumab and topicals such as high-potency corticosteroids with or without a vitamin D analogue can be recommended as a treatment option to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults. (C)
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Ustekinumab may be combined with acitretin to augment efficacy for the treatment of moderate-to-severe plaque psoriasis. (B)
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Ustekinumab may be combined with methotrexate to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults. (B)
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Ustekinumab may be combined with apremilast to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults. (C)
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Ustekinumab may be combined with cyclosporine to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults. (C)
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Ustekinumab may be combined with narrowband ultraviolet phototherapy to augment efficacy for the treatment of moderate-to-severe plaque psoriasis in adults. (B)
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IL-17 antibody secukinumab

Secukinumab is recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis. (A)
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The recommended starting dose of secukinumab is 300 mg by selfadministered subcutaneous injection at wk 0, wk 1, wk 2, wk 3, and wk 4, followed by 300 mg every 4 wk. (A)
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The recommended maintenance dose of secukinumab after the initial 12 wk is 300 mg every 4 wk. (A)
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Secukinumab is recommended at a dose of 300 mg, which is more effective than 150 mg. (A)
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Secukinumab can be recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis affecting the head and neck, including the scalp. (B)
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Secukinumab is recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis affecting the nails. (A)
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Secukinumab is recommended as a monotherapy treatment option in adult patients with moderate-to-severe palmoplantar plaque psoriasis. (A)
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Secukinumab can be recommended as a monotherapy treatment option in adult patients with moderate-to-severe palmoplantar pustulosis. (B)
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Secukinumab can be used as monotherapy in adult patients with erythrodermic psoriasis. (C)
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Secukinumab may be used as monotherapy for adult patients with plaque psoriasis when associated with psoriatic arthritis. (A)
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IL-17 antagonist ixekizumab

Ixekizumab is recommended as a monotherapy treatment option for use in adult patients with moderate-to-severe plaque psoriasis. (A)
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The recommended starting dose of ixekizumab is 160 mg by selfadministered subcutaneous injection followed by 80 mg at wk 2, wk 4, wk 6, wk 8, wk 1, and wk 12. (A)
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The recommended maintenance dose of ixekizumab after the initial 12 wk is 80 mg every 4 wk. (A)
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Ixekizumab can be recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis affecting the scalp. (B)
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Ixekizumab can be recommended as a monotherapy treatment option in adult patients with erythrodermic psoriasis. (B)
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Ixekizumab can be recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis affecting the nails. (B)
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Ixekizumab can be recommended as a monotherapy treatment option in adult patients with generalized pustular psoriasis. (B)
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Ixekizumab is recommended as a monotherapy treatment option in adult patients with plaque psoriasis when associated with psoriatic arthritis. (A)
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IL-17 antibody brodalumab

Brodalumab is recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis. (A)
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Brodalumab can be used as monotherapy in adult patients with generalized pustular psoriasis. (B)
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The recommended dose of brodalumab is 210 mg by self-administered subcutaneous injection at wk 0, wk 1, and wk 2 followed by 210 mg every 2 wk. (A)
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IL-23 inhibitor guselkumab

Guselkumab is recommended as a monotherapy treatment option for use in adult patients with moderate-to-severe plaque psoriasis. (A)
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The recommended dose of guselkumab is 100 mg by self-administered subcutaneous injection at wk 0, wk 4, and every 8 wk thereafter. (A)
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Guselkumab is recommended as a monotherapy treatment option in adult patients with scalp, nail, and plaque-type palmoplantar psoriasis. (A)
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IL-23 inhibitor tildrakizumab

Tildrakizumab is recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis. (A)
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The recommended dose is 100 mg given by in office physician-administered subcutaneous injection at wk 0 and wk 4 and every 12 wks thereafter. (A)
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IL-23 inhibitor risankizumab

Risankizumab is not FDA-approved but can be used as monotherapy in adult patients with moderate-to-severe plaque psoriasis. (B)
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The approved dose will likely be 150 mg given by self-administered subcutaneous injection at wk 0, wk 4, and then every 12 wk. (A)
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Recommendation Grading

Overview

Title

Management and Treatment of Psoriasis with Biologics

Authoring Organization

Publication Month/Year

February 1, 2019

Last Updated Month/Year

January 29, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

 This guideline addresses important clinical questions that arise in psoriasis management and care, providing recommendations based on the available evidence. The treatment of psoriasis with biologic agents will be reviewed, emphasizing treatment recommendations and the role of the dermatologist in monitoring and educating patients regarding benefits as well as associated risks.

Target Patient Population

Patients with psoriasis

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management, Treatment

Diseases/Conditions (MeSH)

D011565 - Psoriasis, D000911 - Antibodies, Monoclonal, D061067 - Antibodies, Monoclonal, Humanized, D058846 - Antibodies, Monoclonal, Murine-Derived, D001691 - Biological Therapy

Keywords

psoriasis, biologic therapy, biologics, monoclonal antibodies

Methodology

Number of Source Documents
325
Literature Search Start Date
January 1, 2008
Literature Search End Date
December 13, 2017