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Psoriasis

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of psoriasis are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2023,2013), the European League Against Rheumatism (EULAR 2023), the National Psoriasis Foundation (NPF/AAD 2021,2020,2019), the British Association of Dermatologists (BAD 2020), the European Dermatology Forum (EDF 2020), the American Academy of Dermatology ...
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Classification and risk stratification

Severity assessment: as per AAD/NPF 2021 guidelines, measure body surface area of involved skin as an important measure of psoriasis severity to risk stratify patient for future.
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Psoriasis Area and Severity Index (PASI)
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When to use
Head and neck: erythema
None
Slight
Moderate
Severe
Very severe
Head and neck: induration
None
Slight
Moderate
Severe
Very severe
Head and neck: desquamation
None
Slight
Moderate
Severe
Very severe
Head and neck: area affected
0%
1-9%
10-29%
30-49%
50-69%
70-89%
90-100%
Upper limbs: erythema
None
Slight
Moderate
Severe
Very severe
Upper limbs: induration
None
Slight
Moderate
Severe
Very severe
Upper limbs: desquamation
None
Slight
Moderate
Severe
Very severe
Upper limbs: area affected
0%
1-9%
10-29%
30-49%
50-69%
70-89%
90-100%
Trunk: erythema
None
Slight
Moderate
Severe
Very severe
Trunk: induration
None
Slight
Moderate
Severe
Very severe
Trunk: desquamation
None
Slight
Moderate
Severe
Very severe
Trunk: area affected
0%
1-9%
10-29%
30-49%
50-69%
70-89%
90-100%
Lower limbs: erythema
None
Slight
Moderate
Severe
Very severe
Lower limbs: induration
None
Slight
Moderate
Severe
Very severe
Lower limbs: desquamation
None
Slight
Moderate
Severe
Very severe
Lower limbs: area affected
0%
1-9%
10-29%
30-49%
50-69%
70-89%
90-100%
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Diagnostic investigations

Initial assessment: as per AAFP 2013 guidelines, evaluate patients with psoriasis for comorbidities, including psychological conditions.
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  • Screening for psoriatic arthritis

  • Screening for viral infections

  • Screening for tuberculosis

  • Screening for CVD

  • Screening for metabolic syndrome

  • Screening for IBD

  • Screening for anxiety and depression

  • Evaluation before biologic therapy

Medical management

Topical therapy, corticosteroids: as per AAFP 2023 guidelines, offer topical corticosteroids as first-line therapy in patients with any form of mild-to-moderate psoriasis.
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  • Topical therapy (vitamin D analogs)

  • Topical therapy (tazarotene)

  • Topical therapy (calcineurin inhibitors)

  • Topical therapy (combination with topicals)

  • Topical therapy (combination with systemic therapy)

  • Topical therapy (salicylic acid)

  • Topical therapy (coal tar)

  • Topical therapy (anthralin)

  • Non-biologic agents (methotrexate)

  • Non-biologic agents (acitretin)

  • Non-biologic agents (apremilast)

  • Non-biologic agents (cyclosporine)

  • Initiating biologic therapy (general considerations)

  • Initiating biologic therapy (contraindications)

  • Initiating biologic therapy (choice of agent)

  • Biologic agents (etanercept)

  • Biologic agents (infliximab)

  • Biologic agents (adalimumab)

  • Biologic agents (ustekinumab)

  • Biologic agents (secukinumab)

  • Biologic agents (ixekizumab)

  • Biologic agents (brodalumab)

  • Biologic agents (guselkumab)

  • Biologic agents (tildrakizumab)

  • Biologic agents (risankizumab)

  • Combination therapy (etanercept in combinations)

  • Combination therapy (infliximab in combinations)

  • Combination therapy (adalimumab in combinations)

  • Combination therapy (ustekinumab in combinations)

Nonpharmacologic interventions

Lifestyle modifications: as per AAD/NPF 2019 guidelines, encourage patients already being monitored for obesity to maintain a healthy lifestyle and keep regularly scheduled follow-up visits with their primary care provider and/or dermatologist.
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Therapeutic procedures

NB-UVB phototherapy, indications: as per AAD/NPF 2019 guidelines, offer NB-UVB phototherapy as monotherapy in adult patients with plaque psoriasis.
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  • NB-UVB phototherapy (dosing)

  • NB-UVB phototherapy (combination therapy)

  • NB-UVB phototherapy (cautions)

  • BB-UVB phototherapy (indications)

  • BB-UVB phototherapy (combination therapy)

  • BB-UVB phototherapy (cautions)

  • Targeted UVB phototherapy (indications)

  • Targeted UVB phototherapy (dosing)

  • Targeted UVB phototherapy (combination therapy)

  • PUVA phototherapy

  • Other phototherapies

Perioperative care

Preoperative management of systemic therapy: as per AAFP 2023 guidelines, discontinue systemic therapies, discussed with the surgical team, for procedures with a moderate risk of postoperative infection (such as intra-abdominal surgery without bowel resection, intrathoracic surgery without lung resection, gynecologic surgery) or a high risk of infection (such as joint replacement, oncologic surgery, bowel resection).
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Specific circumstances

Patients considering conception, pregnancy, and breastfeeding: as per BAD 2020 guidelines, advise female patients of childbearing potential starting biologic therapy for psoriasis to use effective contraception and to discuss conception plans with the consultant supervising their care. Insufficient evidence about the interactions between biologic therapies and contraceptive methods.
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  • Patients with vulvar psoriasis

  • Patients with hepatitis B or C infection

  • Patients with HIV infection

  • Patients with latent tuberculosis

  • Patients at higher risk of cancer

  • Patients with gluten intolerance

Patient education

General counseling: as per BAD 2020 guidelines, agree and formalize arrangements for drug administration, monitoring and follow-up between healthcare providers and the patient receiving treatment.
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Preventative measures

Immunizations: as per BAD 2020 guidelines, do not give live vaccines to patients on biologic therapy and to infant patients (up to 6 months of age) whose mothers have received biologic therapy beyond 16 weeks of gestation. Check individual drug's summary of product characteristics.
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Follow-up and surveillance

Switching between biologic agents: as per BAD 2020 guidelines, take into consideration the following when switching from one drug therapy to another, or when commencing with a therapy washout:
pharmacology of the drugs that are being stopped and started
patient's clinical circumstances
patient's views on the risks and benefits of switching options.
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  • Monitoring during biologic therapy

  • Surveillance for infectious complications