Bruce F. Bebo

Consensus Guidelines for the Management of Plaque Psoriasis

The Canadian Guidelines for the Management of Plaque Psoriasis were reviewed by the entire National Psoriasis Foundation Medical Board and updated to include newly approved agents such as ustekinumab and to reflect practice patterns in the United States, where the excimer laser is approved for psoriasis treatment. Management of psoriasis in special populations is discussed. In the updated guidelines, we include sections on children, pregnant patients or pregnant partners of patients, nursing mothers, the elderly, patients with hepatitis B or C virus infections, human immunodeficiency virus-infected patients, and patients with malignant neoplasms, as well as sections on tumor necrosis factor blockers, elective surgery, and vaccinations.

Treatment of pustular psoriasis: From the medical board of the National Psoriasis Foundation

BACKGROUND A task force of the National Psoriasis Foundation Medical Board was convened to evaluate treatment options for pustular psoriasis. Meetings were held by teleconference. Consensus on treatment of pustular psoriasis was achieved. Pustular psoriasis has been classified into localized and generalized forms. There are a number of treatment modalities, but there is little evidence-based information to guide the management of this type of psoriasis. OBJECTIVES The purpose of this article was to present treatment recommendations to aid in the treatment of patients with pustular psoriasis. METHODS A literature review was conducted to examine treatment options for pustular psoriasis and assess the strength of the literature for each option. RESULTS Overall the quality of the literature about the treatment of pustular psoriasis is weak. Treatment should be governed by the extent of involvement and severity of disease. Acitretin, cyclosporine, methotrexate, and infliximab are considered to be first-line therapies for those with generalized pustular psoriasis. Adalimumab, etanercept, and psoralen plus ultraviolet A are second-line modalities in this setting. Pustular psoriasis in children, in pregnant women, and in localized forms alter which agents are first-line modalities as concerns such as teratogenicity need to be factored into the decisionmaking for the individual patient. LIMITATIONS There are few high-quality studies examining treatment options for pustular psoriasis. CONCLUSIONS Treatment of patients with pustular psoriasis depends on the severity of presentation and patients underlying risk factors. The data are extremely limited for this type of psoriasis and we encourage further exploration.

Treatment of erythrodermic psoriasis: From the medical board of the National Psoriasis Foundation

BACKGROUND Erythrodermic psoriasis is a severe form of psoriasis that can arise acutely or follow a chronic course. There are a number of treatment options, but overall there are few evidence-based data to guide clinicians in managing these challenging cases. OBJECTIVE Our aim was to create treatment recommendations to help dermatologists treat patients with erythrodermic psoriasis. METHODS A task force of the National Psoriasis Foundation Medical Board was convened to evaluate treatment options for erythrodermic or exfoliative psoriasis. Meetings were held by teleconference and were coordinated and funded by the National Psoriasis Foundation. Consensus on treatment of erythrodermic psoriasis was achieved. A literature review was conducted to examine treatment options for erythrodermic psoriasis and the strength of the evidence for each option. RESULTS There is no high-quality scientific evidence on which to base treatment recommendations. Treatment should be dictated by the severity of disease at time of presentation and the patients comorbidities. Cyclosporine and infliximab appear to be the most rapidly acting agents for the treatment of erythrodermic psoriasis. Acitretin and methotrexate are also appropriate first-line choices, although they usually work more slowly. Treating physicians can consider a number of second-line agents, including etanercept or combination therapy, in the treatment of patients with erythrodermic psoriasis. Combination therapy may be more effective than a single-agent approach; there is a paucity of scientific data in this area. All patients should be evaluated for underlying infection. Supportive care can help control disease and patient symptoms if instituted appropriately. Physicians should avoid potential exacerbating agents when managing this challenging disease. LIMITATIONS There are few high-quality studies examining treatment options for erythrodermic psoriasis. CONCLUSION Treatment of patients with erythrodermic psoriasis demands a thorough understanding of the treatment options available. Therapy should be based on acuity of disease and the patients underlying comorbidities. There are limited data available to compare treatment options for erythrodermic psoriasis. Further studies are necessary to explore the optimal treatment algorithm for these patients.

Review of treatment options for psoriasis in pregnant or lactating women: From the Medical Board of the National Psoriasis Foundation

BACKGROUND Treating psoriasis in pregnant and lactating women presents a special challenge. For ethical reasons, prospective randomized control trials have not been conducted in this patient population although these patients do encounter new-onset psoriasis in addition to flares and may require treatment throughout their pregnancies. OBJECTIVE Our aim was to arrive at consensus recommendations on treatment options for psoriasis in pregnant and lactating women. METHODS The literature was reviewed regarding all psoriasis therapies in pregnant and lactating women. RESULTS Topical therapies including emollients and low- to moderate-potency topical steroids are first-line therapy for patients with limited psoriasis who are pregnant or breast-feeding. The consensus was that second-line treatment for pregnant women is narrowband ultraviolet B phototherapy or broadband ultraviolet B, if narrowband ultraviolet B is not available. Lastly, tumor necrosis factor-α inhibitors including adalimumab, etanercept, and infliximab may be used with caution as may cyclosporine and systemic steroids (in second and third trimesters). Some specific strategies may be used to minimize risk and exposure. LIMITATIONS There are few evidence-based studies on treating psoriasis in pregnant and lactating women. CONCLUSIONS Because there will always be a question of ethical concerns placing pregnant and lactating women in prospective clinical trials, investigation of both conventional and biologic agents are unlikely to ever be performed. Some of these medications used to treat psoriasis are known abortifacients, mutagens, or teratogens and must be clearly avoided but others can be used with relative confidence in select patients with appropriate counseling of risks and benefits.

Treatment of severe scalp psoriasis: from the Medical Board of the National Psoriasis Foundation.

BACKGROUND The scalp is the most commonly affected part of the body in patients with psoriasis. Signs and symptoms of scalp psoriasis vary significantly for individual patients. OBJECTIVE A task force of the National Psoriasis Foundation was convened to evaluate treatment options. Our aim was to achieve a consensus for scalp psoriasis therapy. METHODS Reports in the medical literature were reviewed regarding scalp psoriasis therapy. LIMITATIONS There is a paucity of evidence-based and double-blind studies in the treatment of scalp psoriasis particularly for long-term therapy. Many of the studies in scalp psoriasis were designed to attain Food and Drug Administration approval for a medication and not to provide treatment guidance. CONCLUSIONS The recommended short-term or intermittent therapy for scalp psoriasis is topical corticosteroids. The primary alternatives are topical retinoids, vitamin D analogues, and salicylic acid. Combination therapy has many advantages. The choice of an appropriate vehicle is crucial to increase patient compliance. While scalp psoriasis can often be adequately treated with topical therapy, recalcitrant disease may require more aggressive approaches, including systemic agents.

Psoriasis in the elderly: From the Medical Board of the National Psoriasis Foundation

BACKGROUND The continuous increase in the US population older than 65 years and the chronic course of psoriasis make management of psoriasis in the elderly an important health care problem. OBJECTIVE We sought to develop a treatment algorithm for patients with psoriasis who are older than 65 years. METHODS A systematic literature search for studies on elderly patients with psoriasis was performed using MEDLINE. RESULTS We summarize the available published data on therapeutic modalities used in the elderly. We suggest a treatment algorithm including topical medications as first-line treatment for limited disease, with phototherapy, systemic retinoids, methotrexate, and biologics as the first-line systemic treatments for patients with more extensive disease. Cyclosporine should only rarely be used as a second-line systemic treatment for extensive disease in elderly patients with psoriasis. LIMITATIONS Limited data are available regarding treatment modalities specifically for elderly patients with psoriasis. CONCLUSION Appropriate treatment for elderly patients with limited psoriasis includes topical corticosteroids, topical vitamin D analogues, and topical tazarotene. For appropriately monitored elderly patients who have psoriasis with extensive disease, phototherapy, acitretin, methotrexate, alefacept, etanercept, adalimumab, infliximab, and ustekinumab are first-line therapies that can generally be safely used. There remains a need for further research on the management of psoriasis in elderly patients with psoriasis.

Psoriasis and Psoriatic Arthritis: A Public Health Agenda

Robust clinical, biomedical, and public health efforts currently address chronic conditions such as heart disease, diabetes, and cancer. However, similar efforts are less common for nonfatal conditions such as psoriasis, which is estimated to affect between 1% and 3% of the adult population,1,2 and psoriatic arthritis, an inflammatory arthritis found in up to one third of adults with psoriasis.3 Both diseases present a substantial public health burden in terms of healthcare costs (

Dermatologist response rates to a mailed questionnaire: a randomized trial of monetary incentives.

650 million in 1997)1; employment and ability to work4; and quality of life.5,6 In 2008, the National Psoriasis Foundation (NPF) approached the CDC to explore how a public health perspective could be incorporated into existing clinical and biomedical perspectives. In 2010, the U.S. Congress included funding for the CDC … to support the collection of epidemiological and longitudinal data on individuals with psoriasis and psoriatic arthritis, including children and adolescents, to better understand the co-morbidities associated with psoriasis, examine the relationship of psoriasis to other public health concerns, and gain insight into the long-term impact and treatment of these two conditions.7

Dermatologist preferences for treatments to compare in future randomized controlled comparative effectiveness trials for moderate to severe psoriasis

To the Editor: Although surveys are frequently used to collect data from dermatologists, response rates are often low, limiting the generalizability of results.1 Monetary incentives have improved physician survey response but have not been tested in dermatologists.2 Moreover, the effect of incentive size remains unclear.2 This study examines the effect of cash incentives on dermatologist response to a mailed questionnaire and its cost-effectiveness. As part of a study about preferences for psoriasis treatment, we surveyed 1000 dermatologists,3 randomizing each to receive an initial questionnaire packet with either

Obesity and psoriasis: From the Medical Board of the National Psoriasis Foundation

5 or