Management Of Psoriasis With Systemic Nonbiologic Therapies
Publication Date: March 1, 2020
Last Updated: November 1, 2023
Recommendations
Methotrexate in psoriasis therapy
Methotrexate is recommended for the treatment of moderate to severe psoriasis in adults. (A)
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Methotrexate is less effective than adalimumab and infliximab for cutaneous psoriasis. (A)
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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)
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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)
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Methotrexate can be administered orally or subcutaneously. (A)
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A test dose should be considered, especially in patients with impaired kidney function. (B)
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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)
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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)
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Apremilast in psoriasis therapy
Apremilast is recommended for the treatment of moderate to severe psoriasis in adults. (A)
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Cyclosporine therapy in psoriasis
Cyclosporine is recommended for patients with severe, recalcitrant psoriasis. (A)
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Cyclosporine can be recommended for the treatment of erythrodermic, generalized pustular, and/or palmoplantar psoriasis. (B)
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Cyclosporine can be recommended as short-term interventional therapy in patients who flare up while on a pre-existing systemic therapy. (C)
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Acitretin in psoriasis therapy
Acitretin can be recommended as monotherapy for plaque psoriasis. (B)
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Acitretin can be recommended for treatment of erythrodermic, pustular, and palmarplantar psoriasis. (B)
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Acitretin can be recommended as combination therapy with PUVA for psoriasis. (B)
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Acitretin can be combined with BB-UVB for plaque psoriasis. (B)
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Title
Management Of Psoriasis With Systemic Nonbiologic Therapies
Authoring Organizations
American Academy of Dermatology
National Psoriasis Foundation
Publication Month/Year
March 1, 2020
Last Updated Month/Year
November 1, 2023
External Publication Status
Published
Country of Publication
US
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
Scope
Management, Treatment
Diseases/Conditions (MeSH)
D011565 - Psoriasis, D007166 - Immunosuppressive Agents, D058988 - Phosphodiesterase 4 Inhibitors
Keywords
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.