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Management Management

of difficult to treat psoriasis

Difficult to treat psoriasis poses therapeutic challenges but the scenario of systemic treatments is being enriched by the advent of new biologics and small molecule drugs

Paolo Gisondi MD Dermatology and Venereology Section, University Hospital of Verona, Italy

The National Institute for Health and Care Excellence (NICE) clinical guideline on psoriasis recommends topical therapy first line for patients with psoriasis. Where topical therapy is ineffective or disease is extensive (for example, more than 10% of body surface area) then phototherapy or systemic treatment should be considered.1

Topical therapies should be used as intermittent courses and long-term application could be associated with side effects. Indeed, very potent corticosteroids should not be used continuously for more than four weeks at a time, and potent corticosteroids for no more than eight weeks at a time. A break of four weeks should be given between treatments during which vitamin D analogues can be used to maintain disease control. Very potent corticosteroids should not be used for infants or children. Adults treated with intermittent or short courses of potent or very potent corticosteroids and children treated with any corticosteroid should be offered an annual assessment for adverse effects including steroid atrophy.1

The effectiveness of topical therapies in patients with psoriasis could be low because patients’ adherence to them is generally very poor.2

Patient education

and the development of adherence- enhancing interventions, such as the topical treatment optimisation programme (TTOP), would be very helpful.2

Phototherapy with narrow-band UVB light or PUVA is recommended for patients who do not respond to topical treatment. Phototherapy should not be offered to people with extensive history of UV treatments, or genetic predisposition to skin cancer such as xeroderma pigmentosum or familial melanoma.1

Systemic therapy

For patients who do no respond to phototherapy, or when this is not a suitable option, systemic therapy can be considered. NICE sets out eligibility criteria for systemic non-biologic therapy. It is recommended for people whose psoriasis cannot be controlled with topical therapy and has a significant impact on physical, psychological or social wellbeing. In addition, either the psoriasis is extensive, or it is localised and associated with significant functional impairment

and/or high levels of distress including scalp, palmo-plantar or nail involvement, or phototherapy has been ineffective or cannot be used.1

These criteria have been

described in literature as the rule of ‘tens’ by Finlay et al, meaning that in cases of PASI score >10, or body surface area >10 and/or Dermatology Life Quality Index >10, patients are candidates for systemic therapies.3

Due to familiarity over long years of use, methotrexate is commonly considered the first choice conventional systemic therapy for people who fulfil the criteria. Acitretin and cyclosporin are alternative options. In particular, cyclosporin is preferred for those who need rapid or short-term control of a disease flare for example, those with palmo-plantar pustulosis. Cyclosporin is generally used for intermittent courses of 12–16 weeks.


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