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Psoriasis

Key sources
The following summarized guidelines for the evaluation and management of psoriasis are prepared by our editorial team based on guidelines from the European League Against Rheumatism (EULAR 2023), the American Academy of Family Physicians (AAFP 2023; 2013), the National Psoriasis Foundation (NPF/AAD 2021; 2020; 2019), the British Association of Dermatologists (BAD 2020), the American Academy of Dermatology (AAD 2019), the European Society for the Study of Coeliac Disease (ESsCD 2019), and the European Academy of Dermatology and Venereology (EADV 2017).
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Guidelines

1.Classification and risk stratification

Severity assessment: measure BSA of involved skin as an important measure of psoriasis severity to risk stratify patient for future.
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2.Diagnostic investigations

Initial assessment: 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

3.Medical management

Topical therapy, corticosteroids, AAFP: 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)

4.Nonpharmacologic interventions

Lifestyle modifications: 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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5.Therapeutic procedures

Narrowband ultraviolet B phototherapy, indications: offer narrowband UVB phototherapy as monotherapy in adult patients with plaque psoriasis.
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  • Narrowband UVB phototherapy (dosing)

  • Narrowband UVB phototherapy (combination therapy)

  • Narrowband 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

6.Perioperative care

Preoperative management of systemic therapy: 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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7.Specific circumstances

Patients considering conception, pregnancy, and breastfeeding: 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

8.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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9.Preventative measures

Immunizations: 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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10.Follow-up and surveillance

Switching between biologic agents: 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