National Psoriasis Foundation

New guidelines aim to clarify systemics use

Newly published guidelines for treating chronic plaque psoriasis should help clarify when to use systemic drugs to treat the disease, says researcher Dr. Sylvia Hsu, dermatology professor at Baylor College of Medicine in Houston.

The guidelines are published in the Jan. 16 issue of the Archives of Dermatology in an article titled "Consensus Guidelines for the Management of Plaque Psoriasis."

Of specific interest is a table listing the drugs used in the treatment of chronic plaque psoriasis. "It is a bold table," says Hsu, who helped develop it. "The aim is to simplify and clarify when to use these drugs for patients whose psoriasis is beyond topical treatment."

The table summarizes the latest research and thinking on eight systemic medications and when and how to best use them in a way that had not been done before. It should make the use and efficacy information for each medication less wordy and more quickly understandable than in the past, Hsu says.

"It says in plain English which one to choose and when to use it," she says. "The table just spells it right out."

One example is the recommendation that the medication cyclosporine be used as a short-term solution for up to 12 weeks, even though FDA guidelines allow its use for up to 12 months.

"If a patient is going to attend his or her child's wedding in three weeks and his or her plaque psoriasis is severe, cyclosporine would be a good choice because it acts quickly and would lead to clearing in three weeks time," she says. "But past 12 weeks, the risks of side effects increase, so switching over to another medication for the long term would be a better choice."

In a similar way, Hsu says the recommendation that the newer medication ustekinumab (brand name Stelara) be considered a first-line systemic treatment should help physicians avoid the misconception that they need to prescribe systemic medications in a particular order based upon time on the market.

The table lists each drug by name, its classification and/or mechanism of action as well as comments that clearly state how and when each medication is best used, as follows:


Method of Action



Oral retinoid
  • First-line systemic drug for chronic palmoplantar or pustular psoriasis in patients of nonchildbearing potential
  • Limited benefit for plaque psoriasis


Oral calcineurin inhibitor
  • Fast-acting systemic drug that is often used first-line for von Zumbusch pustular psoriasis or erythrodermic psoriasis
  • For intermittent use in periods up to 12 weeks as a short-term agent to control a flare of psoriasis

Methotrexate Sodium

Inhibitor of folate biosynthesis
  • Methotrexate sodium Inhibitor of folate biosynthesis May be used as a first-line systemic drug for plaque psoriasis
  • Compared to cyclosporine, has a more modest effect, but can be used continuously for years or decades


TNF inhibitor
  • May be used as a first-line systemic drug for plaque psoriasis
  • Has higher efficacy and has a lower rate of adverse effects compared with methotrexate


TNF inhibitor
  • Commonly used as a first-line systemic drug for chronic plaque psoriasis


TNF inhibitor
  • Intravenous infusion
  • Fast-acting drug that is often used as a second- or third-line biological for chronic plaque psoriasis


Monoclonal antibody that binds the shared p40 protein subunit of IL-12 and IL-23
  • Favorable results when compared with etanercept in terms of efficacy and safety
  • May be used as a first-line treatment for chronic plaque psoriasis


Hsu hopes new guidelines, and most especially the table, will aid physicians in the task of choosing the best systemic medication for the management of a patient's moderate to severe plaque psoriasis in their day-to-day practice.

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