Management Of Psoriasis With Systemic Nonbiologic Therapies

Publication Date: March 1, 2020
Last Updated: November 1, 2023


Methotrexate in psoriasis therapy

Methotrexate is recommended for the treatment of moderate to severe psoriasis in adults. (A)
Methotrexate is less effective than adalimumab and infliximab for cutaneous psoriasis. (A)
Methotrexate is efficacious for treatment of psoriatic arthritis (peripheral arthritis, but not for axial involvement). In psoriatic arthritis, the efficacy of methotrexate is lower than TNF-inhibitors. (B)
Recommended methotrexate dosage typically ranges from 7.5 to 25 mg weekly. The dose can be given as a single dose or in 3 doses over 24 hours. (B)
Methotrexate can be administered orally or subcutaneously. (A)
A test dose should be considered, especially in patients with impaired kidney function. (B)
Administration of folic acid or folinic acid is recommended to reduce the incidence of GI and hepatic adverse effects. Large folic acid and folinic acid doses may reduce the efficacy of methotrexate. (A)
Combination therapy with methotrexate and NB-UVB phototherapy can be considered for adult patients with generalized plaque psoriasis to enhance efficacy and lower cumulative doses of both treatments. (B)

Apremilast in psoriasis therapy

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

Cyclosporine therapy in psoriasis

Cyclosporine is recommended for patients with severe, recalcitrant psoriasis. (A)
Cyclosporine can be recommended for the treatment of erythrodermic, generalized pustular, and/or palmoplantar psoriasis. (B)
Cyclosporine can be recommended as short-term interventional therapy in patients who flare up while on a pre-existing systemic therapy. (C)

Acitretin in psoriasis therapy

Acitretin can be recommended as monotherapy for plaque psoriasis. (B)
Acitretin can be recommended for treatment of erythrodermic, pustular, and palmarplantar psoriasis. (B)
Acitretin can be recommended as combination therapy with PUVA for psoriasis. (B)
Acitretin can be combined with BB-UVB for plaque psoriasis. (B)

Recommendation Grading



Management Of Psoriasis With Systemic Nonbiologic Therapies

Authoring Organizations

Publication Month/Year

March 1, 2020

Last Updated Month/Year

February 5, 2024

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Document Objectives

This guideline will cover the use of oral-systemic, nonbiologic medication in the treatment of psoriasis.

Target Patient Population

Patients with psoriasis

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Long term care, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Management, Treatment

Diseases/Conditions (MeSH)

D011565 - Psoriasis, D007166 - Immunosuppressive Agents, D058988 - Phosphodiesterase 4 Inhibitors


psoriasis, non-biologics, immunosuppressants

Source Citation

Menter A, Gelfand JM, Connor C, Armstrong AW, Cordoro KM, Davis DMR, Elewski BE, Gordon KB, Gottlieb AB, Kaplan DH, Kavanaugh A, Kiselica M, Kivelevitch D, Korman NJ, Kroshinsky D, Lebwohl M, Leonardi CL, Lichten J, Lim HW, Mehta NN, Paller AS, Parra SL, Pathy AL, Prater EF, Rahimi RS, Rupani RN, Siegel M, Stoff B, Strober BE, Tapper EB, Wong EB, Wu JJ, Hariharan V, Elmets CA. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies. J Am Acad Dermatol. 2020 Jun;82(6):1445-1486. doi: 10.1016/j.jaad.2020.02.044. Epub 2020 Feb 28. PMID: 32119894.

Supplemental Methodology Resources

Methodology Supplement


Number of Source Documents
Literature Search Start Date
January 1, 2011
Literature Search End Date
December 31, 2017