From Medscape Medical News
AAD Develops Guidelines for Psoriasis and Psoriatic Arthritis

Emma Hitt, PhD

February 22, 2011 — Therapeutic recommendations for the treatment of mild, moderate, and severe psoriasis, with and without psoriatic arthritis, have been issued by the American Academy of Dermatology (AAD) and published in the Journal of the American Academy of Dermatology in a 6-part series.

The AAD workgroup obtained evidence through a search of the PubMed/MEDLINE database, spanning from 1960 to 2010. In the first 5 parts of the 6-section guidelines, the authors presented evidence supporting the use of topical treatments, phototherapy, traditional systemic agents, and biological therapies for patients with psoriasis and psoriatic arthritis. In the sixth and final section, reported by Alan Menter, MD, from the Baylor University Medical Center in Dallas, Texas, and colleagues and published online February 7, cases were used to illustrate how to apply the guidelines in clinical practice.

According to the authors, treatment options for psoriasis must be tailored to the individual patient, taking into account "efficacy, side effects, availability, ease of administration, comorbidities, family history, and coexisting diseases."

Treating Limited Psoriasis

Topical corticosteroids of varying strengths are a first-line treatment for limited psoriasis (ie, <5% body surface area). The vitamin D analogs calcipotriene, calcipotriol, and calcitriol may also be used as first-line in certain settings. Other topical approaches include retinoids, tacrolimus, and ultraviolet-based therapy, such as the 308-nm monochromatic xenonchloride (excimer) laser.

Evidence is limited to support the efficacy of emollients and ointments, although they may be able to restore normal hydration and water barrier function to the epidermal layer of the psoriatic plaque, the authors state, adding that such moisturizers are an important aspect of routine skin care for patients with psoriasis.

Patients with limited disease (representing at least 80% of patients with psoriasis) should still be assessed for psoriatic arthritis. If present, or if there is psoriasis in vulnerable areas such as the face, genitals, hands or feet (palmoplantar), scalp, or intertriginous areas that is either unresponsive to topical therapy or interferes with quality of life, more intensive therapy — rather than just topical or ultraviolet-based therapies — should be used.

Other topics on limited disease covered by the guidelines include the topical treatment of inverse/intertriginous, genital, and scalp psoriasis, as well as clinical trials comparing topical agents. Adherence to topical treatment and short-term use of systemic agents in patients with limited disease are also addressed.

"For the majority of patients with limited disease, topical treatments are safe, effective, and convenient provided patients are fully counseled and educated on the multiple nuances of this form of therapy," the authors conclude.

Clinical Care for Moderate to Severe Psoriasis

In patients with moderate to severe psoriasis without psoriatic arthritis, ultraviolet therapy remains an important therapeutic option. Systemic agents, such as methotrexate, cyclosporin, and acitretin, may also be used. In addition, biologic agents are used in the event that traditional systemic agents fail or are not tolerated. Biologic agents approved for the treatment of either psoriasis or psoriatic arthritis include alefacept (psoriasis only), infliximab, etanercept, adalimumab, golimumab (psoriatic arthritis only), and ustekinumab (psoriasis only).

Agents in phase 2/3 clinical trials for moderate to severe psoriasis include an anti-interleukin (IL)-12/23 antibody, briakinumab, anti-IL-17 antibodies, IL-17 receptor blockers, p-selectin inhibitors, and Janus kinase inhibitors.

Psoriatic Arthritis

Psoriatic arthritis develops in 25% to 30% of patients with psoriasis, usually 5 to 12 years after the start of skin involvement. According to the guidelines, in general, it is appropriate to initiate methotrexate treatment for patients with moderate to severe psoriatic arthritis without contraindications. After 12 to 16 weeks without improvement, the patient may be switched to any tumor necrosis factor alpha inhibitor, or a tumor necrosis factor alpha inhibitor may be added to the methotrexate therapy.

Future Research

The authors also identified several gaps in knowledge requiring further study. Topics include, but are not limited to, the comparative efficacy of treatment for various forms of psoriasis; how treatment relates to reduced risk of comorbidities, such as cardiovascular risk; and the genetics underlying the pathology of psoriatic disease.

The report was not commercially funded. The authors' disclosure information is extensive and is listed at the end of the guidelines.

J Am Acad Dermatol. Published online February 7, 2011.