Management of Psoriasis with Systemic Nonbiologic Therapies

Patient Guideline Summary

Publication Date: March 1, 2020

Last Updated: November 1, 2023

Objective

This patient summary means to discuss key recommendations from the American Academy of Dermatology (AAD) for the care for the management of psoriasis with systemic nonbiologic therapies. It is limited to adults 18 years of age and older and should not be used as a reference for children.

Overview

Psoriasis Vulgaris is a chronic inflammatory skin disease.

It typically presents with well-defined pink plaques with a silvery scale.

It commonly involves the scalp, elbows, knees, and presacral region, but it can affect any area of skin.

Psoriasis is an immune-mediated condition.

The same disease process that causes psoriasis often affects joints causing psoriatic arthritis.

Although helpful in most psoriasis treatment regimens, topical therapies are frequently inadequate to get and maintain skin clearance.

This patient summary focuses on the use of oral-systemic, nonbiologic medication in the treatment of psoriasis.

Treatment

Important Note:
For each of the drugs listed below, there are conditions and chronic diseases that forbid their use or advise caution if used. It is important to check them with your doctor. Pregnancy, nursing, liver diseases, blood diseases, allergic reactions, diabetes, immunodeficiency, cancers, decreased kidney function are examples of these conditions.

Methotrexate

Methotrexate may be recommended by your healthcare provider for treatment of moderate to severe psoriasis in adults.
It is less effective than some other medications such as adalimumab and infliximab for psoriasis affecting the skin.
Methotrexate can also be used to treat psoriatic arthritis, but it does not work as well for arthritis affecting the spine.
The usual dose of methotrexate is between 7.5 to 25 mg once weekly. This can be taken as a single dose or split into 3 doses over 24 hours.
Methotrexate can be taken by mouth or injected under the skin.
A test dose may be considered, especially if you have kidney problems.
Taking folic acid or folinic acid with methotrexate can help reduce side effects such as gastro-intestinal and liver problems. But large doses of these supplements may make methotrexate less effective.
Methotrexate together with light therapy may be considered to improve efficacy and reduce the total dose needed of each treatment.

Apremilast

Apremilast may be recommended by your healthcare provider for treatment of moderate to severe psoriasis in adults.

Cyclosporine

Cyclosporine may be recommended by your healthcare provider if you have severe psoriasis that is difficult to treat.
It can also be used for generalized pustular psoriasis and psoriasis affecting the palms and soles.
Cyclosporine may be used short-term if you experience a flare-up while on another systemic medication.

Acitretin

Acitretin alone may be recommended for plaque psoriasis.
It can also be used for erythrodermic, pustular, and palmoplantar psoriasis.
Combining acitretin with light therapy is another option for psoriasis treatment.

Abbreviations

AAD: American Academy Of Dermatology

Source Citation

Menter A, Gelfand JM, Connor C, Armstrong AW, Cordoro KM, Davis DMR, Elewski BE, Gordon KB, Gottlieb AB, Kaplan DH, Kavanaugh A, Kiselica M, Kivelevitch D, Korman NJ, Kroshinsky D, Lebwohl M, Leonardi CL, Lichten J, Lim HW, Mehta NN, Paller AS, Parra SL, Pathy AL, Prater EF, Rahimi RS, Rupani RN, Siegel M, Stoff B, Strober BE, Tapper EB, Wong EB, Wu JJ, Hariharan V, Elmets CA. 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 Jun;82(6):1445-1486. doi: 10.1016/j.jaad.2020.02.044. Epub 2020 Feb 28. PMID: 32119894.

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.