Psoriasis Guidelines
Psoriasis Guidelines
European psoriasis guidelines
European guidelines for the treatment of psoriasis provide an overview of practical aspects relevant to selecting drugs, monitoring patients on therapy, and assessing and managing people with psoriasis, including special populations and those with comorbid conditions1–4.
EuroGuiDerm guidelines (2020/2021)
The EuroGuidDerm guidelines are supported by the European Dermatology Forum, and include a range of recommendations reached through a structured consensus process1,2. Developed following the EuroGuiDerm Guideline and Consensus Statement Development Manual, the guideline recommendations are based on the evaluation of efficacy and safety data, and on the practical experience obtained with different treatment modalities1,2.
Part 1: Psoriasis treatment and monitoring recommendations
This evidence- and consensus-based guideline was released in 2020. It focuses on the treatment of psoriasis vulgaris and presents general treatment recommendations for management of psoriasis and monitoring recommendations for individual drugs1.
Treatment options discussed are: acitretin, ciclosporin, fumarates, methotrexate, adalimumab, apremilast, brodalumab, certolizumab pegol, etanercept, guselkumab, infliximab, ixekizumab, risankizumab, secukinumab, tildrakizumab, and ustekinumab1.
View Part 1 of the EuroGuidDerm guideline (2020) on psoriasis treatment and monitoring
Part 2: Specific clinical and comorbid situations
This guideline was released in 2021, focusing on guidance for management of psoriasis in specific clinical and comorbid situations. These include psoriasis vulgaris with concomitant psoriatic arthritis, inflammatory bowel disease, a history of cancer, or a history of depression or suicidal ideation2. It also addresses psoriasis in the presence of diabetes, viral hepatitis, cardiovascular disease, kidney disease and neurological disease2.
Recommendations on screening for tuberculosis, and managing people with a positive tuberculosis test result, are given. It covers treatment for pregnant women or those planning pregnancy in the near future. Information on vaccination, immunogenicity and systemic treatment during the COVID-19 pandemic is also provided.
German S3 guidelines (2021)
Based on the EuroGuiDerm guidelines, the German S3 guidelines for treatment of psoriasis vulgaris were released in 20213,4. The authors developed the S3 guidelines by adapting, remixing, transforming, translating or building upon the pre-peer reviewed version of the EuroGuiDerm guidelines. The S3 guideline was approved by the German Dermatological Society and the Berufsverband der Deutschen Dermatologen e.V3,4.
In addition to the English translation outlined below, a longer version of the guideline is also available in German.
Part 1: Treatment goals and treatment recommendations
Part 1 of the German S3 guidelines contains recommendations on treatment of psoriasis vulgaris, including treatment goals and consensus-based recommendations on treatment options based on characteristics of patients with psoriasis4.
Part 2: Treatment monitoring and specific clinical or comorbid situations
Part 2 of the German S3 guidelines covers treatment monitoring for patients with psoriasis vulgaris, and specific clinical or comorbid situations3.
Similarly to the EuroGuiDerm guidelines, the specific clinical and comorbid situations addressed in the S3 guideline include psoriatic arthritis, inflammatory bowel disease, cancer, depression, conditions affecting the heart and kidneys, as well as neurological conditions such as multiple sclerosis, viral hepatitis and tuberculosis. Recommendations for management of women with psoriasis who are pregnancy or planning a pregnancy in the near future are also included3.
Spanish guidelines update from the Spanish Academy of Dermatology and Venereology (2022)
A practical, consensus-based update of the Spanish psoriasis guidelines was published by the Psoriasis Group (GPs) of the Spanish Academy of Dermatology and Venereology (AEDV) in 20225,6. It contains updates on treatment of moderate-to-severe psoriasis that have emerged following changes in the treatment paradigm and approval of a large number of new biologic agents in recent years5,6.
This consensus document was developed using a structured approach, incorporating systematic reviews and meta-analyses as well as clinical trials and high-quality real-world studies5,6.
Part 1: Concepts and general management of psoriasis with biologic therapy
Part 1 of this guideline include general principles for the treatment of patients with moderate-to-severe psoriasis, defining treatment goals and criteria for when biologic therapy is indicated, and for the selection of initial and subsequent therapies5. Practical issues, such as treatment failure and maintenance of response, are also addressed5.
Part 2: Management of special populations, patients with comorbid conditions, and risk
Part 2 of this guideline covers management of special populations, comorbidities, and risk in the setting of moderate-to-severe psoriasis treated with biologic therapies6.
- It addresses management of psoriasis in patients older than 65 years, paediatric patients, and women who are pregnant, breastfeeding or planning a pregnancy6
- This guideline also addresses psoriasis management in the setting of patients with comorbidities such as obesity and metabolic syndrome, diabetes, psoriatic arthritis, inflammatory bowel disease, depression, cancer, and conditions affecting the heart, liver and kidneys, as well as neurological disease6
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American Academy of Dermatology (AAD) psoriasis guidelines
The evidence-based American Academy of Dermatology (AAD) guidelines provide treatment recommendations, and emphasise the role of the dermatologist in monitoring and educating people with psoriasis about their benefits and associated risks7–11.
Joint AAD-NPF topical treatment guidelines
Topical medications are the most common agents used to treat mild-to-moderate psoriasis patients7. Alternative Medicine (AM), while not considered part of conventional care, may also benefit a subset of patients7.
Guidelines for the management of psoriasis with topical therapies were developed by American Academy of Dermatology (AAD) in collaboration with the National Psoriasis Foundation (NPF) in 20207.
These guidelines review topical agents and alternative medicine with an emphasis on treatment recommendations as well as the role of dermatologists in monitoring and educating patients on the benefits and risks of these treatments7. The guideline also addresses severity assessment methods of psoriasis7.
View the topical treatment guideline
Joint AAD-NPF guidelines on biologic and non-biologic treatment
Various circumstances drive the decision of a particular medication, including rapidity of onset, individual patient circumstances, and comorbidities.
The joint AAD-NPF guideline observes that anti-TNF biosimilars approved by the FDA should be considered as interchangeable with the reference brand, and that biologics may lose efficacy in patients who initially respond well to treatment8.
While biologic therapies have changed the treatment landscape, many non-biologic therapies are still used either as monotherapy or in combination with biologic medications9. The joint AAD-NPF guideline of care for the management of psoriasis with non-biologics discusses the efficacy and safety of the most commonly used medications, newer therapies, and therapies that are no longer widely used9.
View the non-biologics guideline
Joint AAD-NPF guidelines on management and treatment of psoriasis with awareness and attention to comorbidities
AAD-NPF guidelines were published in 2019 covering the management and treatment of comorbidities that occur in patients with psoriasis.
This guideline provide an overview of the most common comorbidities and recommendations for screening and referral of these conditions10. The importance of patient and physician education surrounding these comorbidities was highlighted by Randy Beranek, president and CEO of the NPF10:
‘It is critical for both patients and doctors to understand the complexity of psoriasis. It is not just a skin disease; it is a serious condition that can affect all aspects of a patient’s health.’
Joint AAD-NPF guidelines of care for the management of psoriasis in paediatric patients
Published in 2019, the joint AAD-NPF guidelines cover care for the management of psoriasis in paediatric patients11.
This guideline highlights the unique physiology, pharmacokinetics, and patient-parent-provider interactions of paediatric patients, and addresses essential clinical questions in the management of psoriasis in paediatric patients. Common comorbidities in paediatric patients are discussed as they are essential to consider when selecting an appropriate management strategy11.
Providing evidence-based recommendations, the topics included mirror the adult guideline sections where relevant11.
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Expert opinion on psoriasis guidelines
In the videos below, listen to commentary from Professor Peter van de Kerkhof, an expert dermatologist from Radboud University Nijmegen in the Netherlands, on current guidelines for psoriasis and how they may evolve in coming years.
Do current guidelines provide distinct definitions for mild, moderate and severe psoriasis?
Will guideline updates offer guidance on oral agents and biologics in people with moderate psoriasis?
The International Psoriasis Council
Psoriasis is such an active field of research, and the pace at which new treatments are becoming approved makes it difficult for the guidelines to keep up. In addition, with the vastly improved treatment armamentarium, it has been recognised that improving the classification of psoriasis severity would be of benefit for treatment decision-making.
The International Psoriasis Council (IPC)12, founded in 2004, is a dermatology-led, global, non-profit organisation with a network of nearly 130 individuals including psoriasis experts, thought leaders, and professionals, dedicated to improving patient care around the globe.
The International Psoriasis Council aims to deepen the understanding of the disease and its management and believe that ultimately a world without psoriasis is possible
Efforts to improve the classification of psoriasis severity
The IPC recognises that the current clinical definitions of psoriasis severity are narrowly defined and overlook the unique challenges faced by each patient, which may include localised lesions in specific areas and/or comorbidities13. A more specific classification of disease severity is needed to improve the care of all people with psoriasis, strengthen treatment guidelines and guide future clinical trials of therapeutics targeting various levels of disease severity13. Therefore, the IPC is undertaking a project that aims to recategorise psoriasis severity13.
IPC project to recategorise psoriasis severity
In phase 1 of the project to recategorise psoriasis severity, the IPC conducted a modified Delphi consensus process among its counsellors to categorise psoriasis severity and to redefine access criteria for systemic therapy13,14. As a result of this work, the IPC suggests that patients who meet one or more of the following criteria can be considered for systemic therapy13:
- Psoriasis lesions on 10% or more of body surface OR
- Psoriasis lesions on sensitive areas of the body (i.e., hands/feet, face, genitals, scalp) OR
- Topical therapy has failed to control symptoms
In Phase II of the project, this categorisation will be tested in real-world studies13.
However, it should be noted that these definitions are not aligned with current guidelines on management of psoriasis1,4,5, and the approved therapeutic indications for psoriasis treatments must also be considered.
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References
- Nast A, Smith C, Spuls PI, Avila Valle G, Bata-Csörgö Z, Boonen H, et al. EuroGuiDerm Guideline on the systemic treatment of Psoriasis vulgaris – Part 1: treatment and monitoring recommendations. Journal of the European Academy of Dermatology and Venereology. 2020;34(11):2461–2498.
- Nast A, Smith C, Spuls PI, Avila Valle G, Bata-Csörgö Z, Boonen H, et al. EuroGuiDerm Guideline on the systemic treatment of Psoriasis vulgaris – Part 2: specific clinical and comorbid situations. Journal of the European Academy of Dermatology and Venereology. 2021;35(2):281–317.
- Nast A, Altenburg A, Augustin M, Boehncke W-H, Härle P, Klaus J, et al. German S3-Guideline on the treatment of Psoriasis vulgaris, adapted from EuroGuiDerm – Part 2: Treatment monitoring and specific clinical or comorbid situations. JDDG: Journal der Deutschen Dermatologischen Gesellschaft. 2021;19(7):1092–1115.
- Nast A, Altenburg A, Augustin M, Boehncke W-H, Härle P, Klaus J, et al. German S3-Guideline on the treatment of Psoriasis vulgaris, adapted from EuroGuiDerm – Part 1: Treatment goals and treatment recommendations. JDDG: Journal der Deutschen Dermatologischen Gesellschaft. 2021;19(6):150–934.
- Carrascosa JM, Puig L, Belinchón Romero I, Salgado-Boquete L, del Alcázar E, Andrés Lencina JJ, et al. [Translated article] Practical Update of the Recommendations Published by the Psoriasis Group of the Spanish Academy of Dermatology and Venereology (GPs) on the Treatment of Psoriasis with Biologic Therapy. Part 1. Concepts and General Management of Psoriasis With Biologic Therapy. Actas Dermosifiliogr. 2022;113(3):T261–T277.
- Carrascosa JM, Puig L, Romero IB, Salgado-Boquete L, del Alcázar E, Lencina JJA, et al. [Translated article] Practical Update of the Guidelines Published by the Psoriasis Group of the Spanish Academy of Dermatology and Venereology (GPs) on the Treatment of Psoriasis With Biologic Agents: Part 2—Management of Special Populations, Patients With Comorbid Conditions, and Risk. Actas Dermosifiliogr. 2022;113(6):T583–T609.
- Elmets CA, Korman NJ, Prater EF, Wong EB, Rupani RN, Kivelevitch D, et al. Joint AAD–NPF Guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures. J Am Acad Dermatol. 2021;84(2):432–470.
- Menter A, Strober BE, Kaplan DH, Kivelevitch D, Prater EF, Stoff B, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. J Am Acad Dermatol. 2019;80(4):1029–1072.
- Menter A, Gelfand JM, Connor C, Armstrong AW, Cordoro KM, Davis DMR, et al. 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;82(6):1445–1486.
- Elmets CA, Leonardi CL, Davis DMR, Gelfand JM, Lichten J, Mehta NN, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities. J Am Acad Dermatol. 2019;80(4):1073–1113.
- Menter A, Cordoro KM, Davis DMR, Kroshinsky D, Paller AS, Armstrong AW, et al. Joint American Academy of Dermatology–National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients. J Am Acad Dermatol. 2020;82(1):161–201.
- The International Psoriasis Council. 2023. https://www.psoriasiscouncil.org/. Accessed 16 May 2023.
- The International Psoriasis Council. Recategorization of psoriasis severity - project description. 2023. https://psoriasiscouncil.org/our-work/projects/disease-severity-classification/. Accessed 16 May 2023.
- Strober B, Ryan C, van de Kerkhof P, van der Walt J, Kimball AB, Barker J, et al. Recategorization of psoriasis severity: Delphi consensus from the International Psoriasis Council. J Am Acad Dermatol. 2020;82(1):117–122.
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