Psoriasis Guidelines

The National Psoriasis Foundation (NPF) and the American Academy of Dermatology (AAD) have released five sections of new clinical guidelines outlining best practices for managing psoriasis. The guidelines, which were published online in the Journal of the American Academy of Dermatology, were developed by an expert group composed of dermatologists, a cardiologist, a rheumatologist and patient representatives.

The published guideline sections relate to biologic therapies, comorbidities, phototherapy, pediatric patients and systemic non-biologic therapies. The sixth section, topicals, is expected in Summer 2020. Together, they represent the first updating of psoriasis treatment guidelines in a decade. They provide health care professionals, patients, insurers and caregivers with the most accurate, up-to-date, evidence-based approaches for the treatment and monitoring of people with psoriasis.

The current published treatment and care recommendations:

Biologics

Biologics only target specific parts of the immune system, differentiating them from traditional systemic drugs that impact the entire immune system.

Biologics are prescribed for individuals with plaque psoriasis and psoriatic arthritis. They are a viable option for those who have not responded to or have experienced harmful side effects from other treatments.

Biologics can have multiple indications. Often, they are indicated for moderate-to-severe plaque psoriasis, but may include other types of psoriasis and psoriatic arthritis.

Your health care provider can help determine if biologics are the appropriate treatment for you.

Comorbidities

Psoriasis is a chronic inflammatory disease that affects multiple systems of the body, not just the skin. Comorbidities associated with psoriasis include psoriatic arthritis (PsA), cardiovascular disease (diseases of the heart and arteries), metabolic syndrome (including type 2 diabetes) and mental illnesses (depression and anxiety). Patients should be screened for these comorbidities, as they can impact a patient's treatment plan. Health care providers and patients should be aware of the need to look for psoriatic joint disease and potential problems with comorbid (related) conditions at each visit. Patients should know that making simple lifestyle changes, such as not smoking and limiting alcohol, may be beneficial.

Learn more about comorbidities by requesting a free comorbidities quick guide.

Phototherapy

There are many different phototherapy treatment options available. However, some are better for certain types of psoriasis. Phototherapy can also be used in combination with other types of psoriasis treatments. A dermatologist should also consider patient preference, including dosing frequency, skin tone (doses may very based on this factor), cost and proximity to a phototherapy unit, before beginning phototherapy treatment.

Pediatric Patients

Psoriasis affects approximately 1 percent of children, with the disease starting most often in adolescence. Monitoring and treating the emotional health of children and teens with psoriasis is important, due to potential teasing and bullying by their peers. Fortunately, treatment options for this population have improved, and evidence-based recommendations are presented. The new guideline is divided into sections focused on the overall management of psoriasis in the pediatric population.

Systemic Non-Biological Therapies

Provides a detailed discussion of the efficacy and safety of the most commonly used medications – including methotrexate, cyclosporine and acitretin – and recommendations to assist prescribers in initiating and managing patients on these treatments. The guideline discusses newer therapies, including tofacitinib and apremilast, and briefly reviews other medications, including therapies that are no longer widely used for the treatment of psoriasis.

Topical Therapies

Provide recommendations for the use of topical treatment and emphasize dermatologists’ role in monitoring and educating patients about benefits and risks associated with this treatment option. The guidelines also covers recommendations on how to assess the severity of psoriasis using different tools such as BSA, PASI, PGA, and others that can be used in clinical practice.

Also included is an alternative medicine section, which summarizes the treatment of psoriasis with traditional Chinese medicine, herbal therapies, diet regimen, and wellness activities. Due to the lack of or conflicting evidence, however, the guidelines do not provide recommendations about the use of these alternative options.

Psoriasis Guideline FAQ

Do these guidelines apply to me? What should I do?

The guidelines apply to you if you have been diagnosed with psoriasis. Ask your dermatologist about what the guidelines mean for your treatment, especially if you have moderate-to-severe psoriasis and you’re not already taking a biologic.

How worried should I be of comorbidities?

Concern about comorbidities shouldn’t rule your life, but you shouldn’t rule them out, either. There’s a lot more to psoriasis than what you see on you skin. Share your concerns with your primary care provider and with your dermatologist, if you have one. Your dermatologist is the key player in your psoriasis treatment team, but dermatologists are usually not specialized in treating conditions such as heart disease, diabetes or hypertension. Your dermatologist should work with your primary care provider in these and other areas.

What if I don’t have a dermatologist?

We can help you find one. Just contact our Patient Navigation Center for free assistance locating a health care provider in your area who truly understands psoriasis and its comorbidities. Patient navigators can also offer resources if you have other questions about psoriatic disease.

How do I talk about the guidelines with my dermatologist? What if he or she hasn’t heard of them?

Doctors are busy people, but they want to hear your concerns. Start by doing a little homework. Read our story on the guidelines or access the full articles about biologics, comorbidities, phototherapy and pediatrics from the Journal of the Academy of American Dermatologists. Ask your doctor how the guidelines apply to you.

April Armstrong, M.D., MPH, director of the psoriasis program in the Department of Dermatology at the University of Southern California and an NPF medical board member, cautions against appearing confrontational when bringing up the topic of treatment guidelines.

“Some providers who do not know about the guidelines may need time to read about them, digest them, and think about how these approaches can be applied to their individual patients,” she says. “If they are initially unaware of these guidelines, please do not act as if they should know them. Rather, ask them to visit the NPF site to read more about them. You can always come back to this issue at your next visit.”

Your patient navigator can help you prep for this conversation.

Do the guidelines tell my doctor what to do?

Definitely not.

Alan Menter, M.D., is one of the two co-chairs of the guidelines team. He is the chair of the Division of Dermatology and director of the Dermatology Residency Program at Baylor University Medical Center in Dallas. He received an NPF Lifetime Achievement Award in 2013. Menter says that the guidelines do not tell doctors how to treat their patients. They do not define the standard of care or take the place of the conversations you should be having with your doctor about your treatment plan.

Instead, the guidelines provide an education. “Thanks to these guidelines, your health care provider now has the clinical evidence of the past 10 years, including biologic treatments and the latest findings on comorbidities, at his or her fingertips,” Menter says. “You can learn this, too. You should work in partnership with your doctor to find the treatment that works for you and that you want to do.”