A new joint statement from the American Academy of Dermatology (AAD) and the National Psoriasis Foundation (NPF) provides clinicians updated guidance on the use of systemic and non-biologic medications for the treatment of psoriasis. The guideline was published in the Journal of the American Academy of Dermatology.

The guideline was formulated by experts in the field and members of the AAD and NPF. The first recommendations focused on commonly prescribed treatments for psoriasis. Methotrexate, for example, has been a treatment for psoriasis for more than 5 decades. Based on expert opinion, physicians may consider starting a test dose of methotrexate at 2.5 mg to 5 mg followed by a complete blood count approximately 5 to 7 days after the test dose, which can provide insight into individual susceptibility to bone marrow suppression.

Physicians could also begin methotrexate at a therapeutic dose such as 15 mg weekly, adjusting the dose as needed to achieve adequate skin clearance while ensuring the number of adverse events remains low. The strength A recommendation made by the AAD and NPF encourages administration of folic or folinic acid in conjunction with methotrexate to reduce gastrointestinal and hepatic adverse events associated with the medication.

A total of 3 recommendations were made for cyclosporine, a common immunosuppressant drug used for psoriasis. The guideline recommends cyclosporine for severe, recalcitrant psoriasis (strength A recommendation). The strength B recommendation in the guideline states cyclosporine can also be used for treating erythrodermic, generalized pustular, and/or palmoplantar psoriasis. In addition, cyclosporine may be considered for short-term use in patients with disease flares during pre-existing systemic therapy.


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All recommendations made for acitretin, another common treatment option for psoriasis, had B-level recommendation strengths. The guideline recommends acitretin monotherapy for plaque psoriasis. In addition, acitretin is recommended by the AAD-NPF guideline for treating erythrodermic, pustular, and palmar-plantar psoriasis. In addition to the monotherapy recommendation, the committee members wrote that acitretin can be combined with psoralen and ultraviolet radiation for psoriasis or broad-band ultraviolet B light for plaque psoriasis.

Several new therapies, including tofacitinib and apremilast, also had supporting statements in the guideline. Tofacitinib, which is not currently approved for moderate to severe psoriasis, can still be considered for use in this disease. The Zoster vaccine should be considered before using tofacitinib to reduce herpes zoster risk. Apremilast, which was approved in 2014, is recommended by the guideline for the treatment of moderate to severe psoriasis in adults (strength A recommendation).

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The AAD and NPF wrote that the medications listed in this guideline “can benefit widespread psoriasis, have a comparatively low-cost in the case of older medications, have increased availability, and ease of administration.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Menter A, Gelfand JM, Connor C, et al. Joint AAD-NPF guidelines of care for the management of psoriasis with systemic non-biological therapies [published online February 28, 2020]. J Am Acad Dermatol. doi:10.1016/j.jaad.2020.02.044