Management and Treatment of Psoriasis with Biologics Clinical Practice Guidelines (2019)

American Academy of Dermatology and the National Psoriasis Foundation

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

March 01, 2019

Guidelines on the management and treatment of psoriasis with biologics were released in February 2019 by the American Academy of Dermatology and the National Psoriasis Foundation.[1]

TNF-alpha Inhibitors

Etanercept recommendations are as follows:

  • Monotherapy treatment option for adults with moderate-to-severe plaque psoriasis

  • Recommended starting dose of 50 mg; self-administered SC injection twice weekly for 12 consecutive weeks

  • Recommended maintenance dose of 50 mg once weekly; 50 mg twice weekly is more efficacious than once weekly and may be required for better disease control in some patients

  • Recommended as monotherapy option in adults with moderate-to-severe plaque psoriasis affecting the scalp or nails

  • Can be recommended as monotherapy option for adults with other subtypes (ie, pustular, erythrodermic) of moderate-to-severe plaque psoriasis

  • Recommended monotherapy option in adults with plaque psoriasis of any severity when associated with significant psoriatic arthritis

  • Recommended combination treatment option with topicals (eg, high-potency corticosteroids with or without a vitamin D analogue) to augment treatment of moderate-to-severe plaque psoriasis

  • Recommended combination treatment option with methotrexate for moderate-to-severe plaque psoriasis in adults

  • May be combined with acitretin, apremilast, cyclosporine, or narrowband ultraviolet phototherapy for moderate-to-severe plaque psoriasis in adults

Infliximab recommendations are as follows:

  • Monotherapy treatment option for adults with moderate-to-severe plaque psoriasis

  • Recommended starting dose is an infusion of 5 mg/kg administered at week 0, week 2, and week 6; thereafter, administered every 8 weeks

  • Recommended to be administered at more frequent intervals (less than q8wk and as frequently as q4wk during maintenance phase) and/or at a higher dose (up to 10 mg/kg) for better disease control in some adults

  • Recommended as monotherapy option for moderate-to-severe plaque psoriasis affecting the palms and soles (plaque-type palmoplantar psoriasis), nails, or scalp in adults

  • Can be recommended as monotherapy option in adults with other subtypes (ie, pustular, erythrodermic) of moderate-to-severe plaque psoriasis

  • Recommended as monotherapy option in adults with plaque psoriasis of any severity when associated with significant psoriatic arthritis; it also inhibits radiographically detected joint damage in psoriatic arthritis

  • Recommended combination treatment option with topicals (eg, high-potency corticosteroids with or without a vitamin D analogue) to augment treatment of moderate-to-severe plaque psoriasis

  • May be combined with acitretin, methotrexate, or apremilast for moderate-to-severe plaque psoriasis in adults

Adalimumab recommendations are as follows:

  • Monotherapy treatment option for adults with moderate-to-severe plaque psoriasis

  • Recommended starting dose of 80 mg taken as two self-administered SC 40-mg injections, followed by a 40-mg self-administered SC injection 1 week later, followed by 40-mg self-administered SC injections every 2 weeks thereafter

  • Maintenance dose of 40 mg/wk recommended for better disease control in some patients

  • Recommended as monotherapy option for adults with moderate-to-severe plaque psoriasis affecting the palms and soles (palmoplantar psoriasis), nails, or scalp

  • Can be recommended as monotherapy option for adults patients with other subtypes (ie, pustular, erythrodermic) of moderate-to-severe psoriasis

  • Recommended as monotherapy option in adults with plaque psoriasis of any severity when associated with psoriatic arthritis

  • Can be recommended combination treatment option with topicals (eg, high-potency corticosteroids with or without a vitamin D analogue) to augment treatment of moderate-to-severe plaque psoriasis

  • May be combined with acitretin, methotrexate, apremilast, cyclosporine, or narrowband ultraviolet phototherapy for moderate-to-severe plaque psoriasis in adults

Certolizumab has been approved by the FDA for the treatment of plaque psoriasis, psoriatic arthritis, Crohn disease, ankylosing spondylitis, and rheumatoid arthritis. Approved dosing for moderate-to-severe psoriasis is 400 mg (two 200-mg SC injections) every other week. It is likely to possess class characteristics similar to those of other TNF-alpha inhibitors.

Interleukin-12/23 Inhibitors

Ustekinumab recommendations are as follows:

  • Monotherapy treatment option for adults with moderate-to-severe plaque psoriasis

  • Recommended starting doses: (1) patients weighing 100 kg or less, 45 mg SC initially and 4 weeks later, followed by 45 mg administered SC every 12 weeks; (2) patients weighing more than 100 kg, 90 mg administered SC initially and 4 weeks later, followed by 90 mg administered SC every 12 weeks

  • Recommended alternate dosages are higher doses (90 mg instead of 45 mg in patients weighing ≥100 kg) or with greater frequency (eg, every 8 wk in maintenance phase) if response to standard dosing is inadequate

  • Can be used as monotherapy option for adults with moderate-to-severe plaque psoriasis affecting the palms and soles (plaque-type palmoplantar psoriasis), nails, or scalp

  • Can be used as monotherapy option for adults with other subtypes (ie, pustular, erythrodermic) of moderate-to-severe psoriasis; evidence is limited for use in inverse and guttate psoriasis

  • Recommended as monotherapy option in adults with plaque psoriasis of any severity when associated with psoriatic arthritis

  • Can be recommended combination treatment option with topicals (eg, high-potency corticosteroids with or without a vitamin D analogue) to augment treatment of moderate-to-severe plaque psoriasis

  • May be combined with acitretin, methotrexate, apremilast, cyclosporine, or narrowband ultraviolet phototherapy for moderate-to-severe plaque psoriasis in adults

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