AAD/NPF Provide Exhaustive Recommendations for Psoriasis Treatment
Experts from the American Academy of Dermatology and the National Psoriasis Foundation teamed up to offer an extensive set of guidelines for the management of psoriasis.
“This portion of the psoriasis guideline addresses clinical questions regarding 12 nonbiologic medications,” Dawn Marie R. Davis, MD, professor of dermatology and pediatrics at the Mayo Clinic in Rochester, Minnesota, and member of the Healio Dermatology Peer Perspective Board, said in an interview.
Davis and colleagues offered an exhaustive discussion that begins with methotrexate, cyclosporine and acitretin, which are the most commonly used medications for this indication. The paper then moves to data for tofacitinib and apremilast and ultimately addresses fumaric acid esters, which are used outside the U.S., along with therapies that are not approved for psoriasis, including hydroxyurea, leflunomide, mycophenolate mofetil, thioguanine and others.
Regarding methotrexate, the authors offer a level A recommendation for use orally or subcutaneously in patients with moderate to severe psoriasis. Folic acid or folinic acid may aid in reducing gastrointestinal and hepatic complications associated with methotrexate. However, they may reduce its efficacy.
“This guidance specifically addresses the workup for evaluating hepatic fibrosis,” Davis said. “Methotrexate is thought to be less effective than adalimumab or infliximab for cutaneous psoriasis.”
Turning to apremilast, Davis said that the drug is recommended for the treatment of moderate to severe psoriasis in adults. Diarrhea, nausea, upper respiratory tract infections and headache may occur. In patients older than 65 years, dehydration and its attendant complications have also been reported.
“Cyclosporine is recommended for patients with severe, recalcitrant psoriasis,” Davis said. “Cyclosporine is a good treatment option for patients with particular psoriasis variants, including erythrodermic psoriasis, generalized pustular psoriasis and palmoplantar psoriasis.”
Contraindications to cyclosporine include UVA treatment or radiation therapy, abnormal renal function, uncontrolled hypertension, malignancy and hypersensitivity to cyclosporine, according to the authors. “Live vaccinations should be avoided,” they wrote. Caution was also encouraged in patients with major infections and poorly controlled diabetes.
While there is no level A recommendation for acitretin, it may be used as monotherapy in plaque psoriasis and may also be used in erythrodermic, pustular and palmoplantar psoriasis. “Acitretin can be used in the treatment of psoriasis as monotherapy or in combination with PUVA or UVB,” Davis said. “Acitretin should not be used in patients who are pregnant, plan to become pregnant or are actively breastfeeding.”
“Several nonbiologics are discussed in the guideline but are not FDA approved for psoriasis at this time,” Davis said. “These include tofacitinib, hydroxyurea, mycophenolate mofetil, azathioprine, leflunomide, tacrolimus and thioguanine.”
While tofacitinib can be considered for treatment of moderate to severe psoriasis, it currently does not have FDA approval for that indication.
Similarly, dimethyl fumarate can be recommended for psoriasis but only has FDA approval for relapsing forms of multiple sclerosis. Patients with severe liver, gastrointestinal or kidney disease are not good candidates for dimethyl fumarate, nor are patients with malignancy, leukopenia or other hematologic abnormalities, those who are pregnant or those who are breastfeeding.
Looking at mycophenolate mofetil, which is also not FDA approved for psoriasis, hypersensitivity to this drug or mycophenolic acid are the key contraindications.
Clinicians are encouraged to view the full document for dosing and other information for all drugs addressed by the joint AAD/NPF guidelines.