NICE Guidelines for Assessment and Management of Psoriasis

The recommendations on Psoriasis in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgment, professionals and practitioners are expected to take this guideline.

The current guideline covers assessing and managing psoriasis in adults, young people, and children. It aims to improve long-term disease control and quality of life for people with psoriasis.

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available.

Recommendations

This guideline includes recommendations on:

• principles of care


• assessment and referral


• topical therapy


• phototherapy


• systemic therapy

Recommendations for Principles of care

1.Offer people with any type of psoriasis, support and information tailored to suit their individual needs and circumstances, in a range of different formats so they can confidently understand:

• their diagnosis and treatment options


• relevant lifestyle risk factors


• how to use prescribed treatments safely and effectively (for example, how to apply topical treatments, how to minimize the risk of side effects through monitoring for the safety of medicines)


• when and how to seek further general or specialist review

2. When offering treatments to a person with any type of psoriasis:

• ensure the treatment strategy is developed to meet the person’s health goals so that the impact of their condition is minimized and use relevant assessment tools to ensure these goals are met


• take into account the age and individual circumstances of the person, disease phenotype, severity and impact, co-existing psoriatic arthritis, comorbidities and previous treatment history


• discuss the risks and benefits of treatment options with the person (and their families or carers where appropriate).


• discuss the importance of adherence to treatment for optimizing outcomes.

3. Assess whether support and information need updating or revising at every review or interaction with the person, in particular:

• during transition from children’s services to adult services


• when new interventions become available


• when the person’s disease severity or circumstances (for example, in terms of comorbidities or lifestyle) change.

Recommendations for Assessment and referral

Assessment tools for disease severity and impact and when to refer for specialist care.

1.For people with any type of psoriasis assess:

• disease severity


• the impact of disease on physical, psychological and social wellbeing


• whether they have psoriatic arthritis


• the presence of co morbidities.

2. Assess the severity and impact of any type of psoriasis:

3. When assessing the disease severity in any healthcare setting, record:

• the results of a static Physician’s Global Assessment (classified as clear, nearly clear, mild, moderate, severe or very severe)^f


• the patient’s assessment of current disease severity, for example, using the static Patient’s Global Assessment (classified as clear, nearly clear, mild, moderate, severe or very severe)


• the body surface area affected


• any involvement of nails, high-impact and difficult-to-treat sites (for example, the face, scalp, palms, soles, flexures and genitals)


• any systemic upset, such as fever and malaise, which are common in unstable forms of psoriasis such as erythroderma or generalised pustular psoriasis.

4. In specialist settings, use a validated tool to assess severity of psoriasis, for example the Psoriasis Area and Severity Index (PASI).

Be aware that:

• PASI and body surface area are not validated for use in children and young people


• erythema may be underestimated in people with darker skin types, such as skin types V and VI on the Fitzpatrick scale.

5. Use the Nail Psoriasis Severity Index to assess nail disease in specialist settings:

• if there is a major functional or cosmetic impact

6. Assess the impact of any type of psoriasis on physical, psychological and social wellbeing by asking:


7. In specialist settings, and if practical in non-specialist settings, use a validated tool to assess the impact of any type of psoriasis on physical, psychological and social wellbeing, for example the:

• Dermatology Life Quality Index (DLQI) for adults or


• Children’s Dermatology Life Quality Index (CDLQI for children and young people.

When using an assessment tool for a person with any type of psoriasis:

• take account of their age, any disabilities (such as physical, visual or cognitive impairment), and any language or other communication difficulties, and provide help and support if needed

8. Following assessment in a non-specialist setting, refer people for dermatology specialist advice if:

• there is diagnostic uncertainty or


• any type of psoriasis is severe or extensive, for example more than 10% of the body surface area is affected or


• any type of psoriasis cannot be controlled with topical therapy or


• acute guttate psoriasis requires phototherapy) or


• nail disease has a major functional or cosmetic impact or

9. People with generalised pustular psoriasis or erythroderma should be referred immediately for same-day specialist assessment and treatment.

10.Refer children and young people with any type of psoriasis to a specialist at presentation

Assessment and referral for psoriatic arthritis

11.Offer annual assessment for psoriatic arthritis to people with any type of psoriasis. Assessment is especially important within the first 10 years of onset of psoriasis.

12. Use a validated tool to assess adults for psoriatic arthritis in primary care and specialist settings, for example, the Psoriasis Epidemiological Screening Tool (PEST). Be aware that the PEST does not detect axial arthritis or inflammatory back pain.

13. As soon as psoriatic arthritis is suspected, refer the person to a rheumatologist for assessment and advice about planning their care.

14. For people with multiple comorbidities and/or multimorbidities and any type of psoriasis needing second- or third-line therapy, ensure multidisciplinary working and communication between specialties and, if needed, interdisciplinary team working (for example when both skin and joints are significantly affected).


15. Be aware that psoriasis of any type, especially if severe, is a risk factor for venous thromboembolism in adults, and:

• explain this risk to adults with any type of psoriasis


• offer advice on how to minimize the risk

16. Assess whether people with any type of psoriasis are depressed when assessing disease severity and impact, and when escalating therapy.

Recommendations regarding Topical therapy

General recommendations

1. Offer people with psoriasis topical therapy as first-line treatment.

Offer second- or third-line treatment options (phototherapy or systemic therapy) at the same time when topical therapy alone is unlikely to adequately control psoriasis, such as:

• extensive disease (for example more than 10% of body surface area affected) or


• at least ‘moderate’ on the static Physician’s Global Assessment or


• where topical therapy is ineffective, such as nail disease.

2. Offer practical support and advice about the use and application of topical treatments. Advice should be provided by healthcare professionals who are trained and competent in the use of topical therapies. Support people to adhere to treatment in line with ‘Medicines adherence’

3. When offering topical agents:

• take into account patient preference, cosmetic acceptability, practical aspects of the application and the site(s) and extent of psoriasis to be treated


• be aware that topical treatment alone may not provide satisfactory disease control, especially in people with psoriasis that is extensive (for example more than 10% of body surface area affected) or at least ‘moderate’ on the static Physician’s Global Assessment.

4.If a person of any age with psoriasis requiring topical therapy has a physical disability, or cognitive or visual impairment offer advice and practical support that take into account the person’s individual needs.

5 Arrange a review appointment 4 weeks after starting a new topical treatment in adults, and 2 weeks after starting a new topical treatment in children, to:

• evaluate tolerability, toxicity, and initial response to treatment (including measures of severity and impact described in recommendations )

6.Discuss with people whose psoriasis is responding to topical treatment (and heir families or carers where appropriate):

• the importance of continuing treatment until a satisfactory outcome is achieved (for example clear or nearly clear) or up to the recommended maximum treatment period for corticosteroids


• that relapse occurs in most people after treatment is stopped


• that after the initial treatment period topical treatments can be used when needed to maintain satisfactory disease control.

7. Offer people with psoriasis a supply of their topical treatment to keep at home for the self-management of their condition.

8. In people whose psoriasis has not responded satisfactorily to a topical treatment strategy, before changing to an alternative treatment:

• discuss with the person whether they have any difficulties with application, cosmetic acceptability or tolerability and where relevant offer an alternative formulation


• consider other possible reasons for non-adherence in line with ‘Medicines adherence’.

How to use corticosteroids safely

9. Be aware that continuous use of potent or very potent corticosteroids may cause:

• irreversible skin atrophy


• psoriasis to become unstable


• systemic side effects when applied continuously to extensive psoriasis (for example more than 10% of body surface area affected).

10. Aim for a break of 4 weeks between courses of treatment with potent or very potent corticosteroids. Consider topical treatments that are not steroid-based (such as vitamin Dor vitamin D analogs or coal tar) as needed to maintain psoriasis disease control during this period.

11.When offering a corticosteroid for topical treatment select the potency and formulation based on the person’s need.

12. Do not use very potent corticosteroids continuously at any site for longer than 4 weeks.

13. Do not use potent corticosteroids continuously at any site for longer than 8 weeks.

14. Do not use very potent corticosteroids in children and young people.

15. Offer a review at least annually to adults with psoriasis who are using intermittent or short-term courses of a potent or very potent corticosteroid (either as monotherapy or in combined preparations) to assess for the presence of steroid atrophy and other adverse effects.

16. Offer a review at least annually to children and young people with psoriasis who are using corticosteroids of any potency (either as monotherapy or in combined preparations) to assess for the presence of steroid atrophy and other adverse effects.

Topical treatment of psoriasis affecting the trunk and limbs

17. Offer a potent corticosteroid applied once daily plus vitamin D or a vitamin D analog applied once daily (applied separately, one in the morning and the other in the evening) for up to 4 weeks as an initial treatment for adults with trunk or limb psoriasis.

18. If the once-daily application of a potent corticosteroid plus once-daily application of vitamin D or a vitamin D analog does not result in clearance, near clearance or satisfactory control of trunk or limb psoriasis in adults after a maximum of 8 weeks, offer vitamin D or a vitamin D analog alone applied twice daily.

19. Offer treatment with very potent corticosteroids in adults with trunk or limb psoriasis only:

• in specialist settings under careful supervision


• when other topical treatment strategies have failed


• for a maximum period of 4 weeks.

20.Consider short-contact dithranol for treatment-resistant psoriasis of the trunk or limbs and either:

• give educational support for self-use or


• ensure treatment is given in a specialist setting.

21.For children and young people with trunk or limb psoriasis consider^s either:

• calcipotriol applied once daily (only for those over 6 years of age) or


• a potent corticosteroid applied once daily (only for those over 1 year of age).

Topical treatment of psoriasis affecting the scalp

22. Offer a potent corticosteroid applied once daily for up to 4 weeks^u as initial treatment for people with scalp psoriasis.

23. Show people with scalp psoriasis (and their families or carers where appropriate) how to safely apply corticosteroid topical treatment.

24.If treatment with a potent corticosteroids does not result in clearance, near clearance or satisfactory control of scalp psoriasis after 4 weeksu consider:

• a different formulation of the potent corticosteroid (for example, a shampoo or mousse) and/or


• topical agents to remove adherent scale (for example, agents containing salicylic acid, emollients and oils) before application of the potent corticosteroid.

25.If the response to treatment with a potent corticosteroid for scalp psoriasis remains unsatisfactory after a further 4 weeks of treatment offer:

• a combined product containing calcipotriol monohydrate and betamethasone dipropionate applied once daily for up to 4 weeks or


• vitamin Dor a vitamin D analogue applied once daily (only in those who cannot use steroids and with mild to moderate scalp psoriasis).

26. If continuous treatment with either a combined product containing calcipotriol monohydrate and betamethasone dipropionate applied once daily or vitamin D or a vitamin D analog applied once daily for up to 8 weeks does not result in clearance, near clearance or satisfactory control of scalp psoriasis offer:

• a very potent corticosteroid applied up to twice daily for 2 weeks for adults only or


• coal tar applied once or twice daily or


• referral to a specialist for additional support with topical applications and/or advice on other treatment options.

27. Consider topical vitamin D or a vitamin D analogue alone for the treatment of scalp psoriasis only in people who:

• are intolerant of or cannot use topical corticosteroids at this site or


• have mild to moderate scalp psoriasis.

28. Do not offer coal tar-based shampoos alone for the treatment of severe scalp psoriasis.

Topical treatment of psoriasis affecting the face, flexures and genitals

29. Offer a short-term mild or moderate potency corticosteroids applied once or twice daily (for a maximum of 2 weeks) to people with psoriasis of the face, flexures or genitals.

30. Be aware that the face, flexures and genitals are particularly vulnerable to steroid atrophy and that corticosteroids should only be used for short-term treatment of psoriasis (1–2 weeks per month). Explain the risks to people undergoing this treatment (and their families or carers where appropriate) and how to minimize them.

31 For adults with psoriasis of the face, flexures or genitals if the response to short-term moderate potency corticosteroids is unsatisfactory, or they require continuous treatment to maintain control and there is serious risk of local corticosteroid-induced side effects, offer a calcineurin inhibitor applied twice daily for up to 4 weeks. Calcineurin inhibitors should be initiated by healthcare professionals with expertise in treating psoriasis.

32. Do not use potent or very potent corticosteroids on the face, flexures or genitals.


33. When prescribing topical agents at facial, flexural and genital sites take into account that they may cause irritation and inform people undergoing treatment (and their families and carers where appropriate) of these risks and how to minimize them.

Recommendations for Phototherapy (broad- or narrow-band (UVB) light and PUVA)

Offer narrowband ultraviolet B (UVB) phototherapy to people with plaque or guttate-pattern psoriasis that cannot be controlled with topical treatments alone. Treatment with narrowband UVB phototherapy can be given 3 or 2 times a week depending on patient preference. Tell people receiving narrowband UVB that a response may be achieved more quickly with treatment 3 times a week.

1.Offer alternative second- or third-line treatment when:

• narrowband UVB phototherapy results in an unsatisfactory response or is poorly tolerated or


• there is a rapid relapse following completion of treatment (rapid relapse is defined as greater than 50% of baseline disease severity within 3 months) or


• accessing treatment is difficult for logistical reasons (for example, travel, distance, time off work or immobility) or


• the person is at especially high risk of skin cancer.

2. Consider psoralen(oral or topical) with local ultraviolet A (PUVA) irradiation to treat palmoplantar pustulosis.

3.When considering PUVA for psoriasis (plaque type or localised palmoplantar pustulosis) discuss with the person:

• other treatment options


• that any exposure is associated with an increased risk of skin cancer (squamous cell carcinoma)


• that subsequent use of ciclosporin may increase the risk of skin cancer, particularly if they have already received more than 150 PUVA treatments


• that risk of skin cancer is related to the number of PUVA treatments.

4. Do not routinely offer co-therapy with acitretinwhen administering PUVA.

5. Consider topical adjunctive therapy in people receiving phototherapy with broadband or narrowband UVB who:

• have plaques at sites that are resistant or show an inadequate response (for example, the lower leg) to phototherapy alone, or at difficult-to-treat or high-need, covered sites (for example, flexures and the scalp), and/or


• do not wish to take systemic drugs or in whom systemic drugs are contraindicated.

6. Do not routinely use phototherapy (narrowband UVB, broadband UVB or PUVA) as maintenance therapy.


7. Ensure that all phototherapy equipment is safety-checked and maintained in line with local and national policy.

8.Healthcare professionals who are giving phototherapy should be trained and competent in its use and should ensure an appropriate clinical governance framework is in place to promote adherence to the indications for and contraindications to treatment, dosimetry and national policy on safety standards for phototherapy.

Risk of skin cancer and how to minimise risk

9.Do not use PUVA in people with psoriasis of any type and a genetic predisposition to skin cancer for example, xeroderma pigmentosum or familial melanoma

10.Do not use PUVA when other appropriate treatments are available in:

• people with a personal history of skin cancer or


• people who have already received 150 PUVA treatments or

11. Use PUVA with caution or consider other treatment options in:

• people at risk of skin cancer (melanoma and non-melanoma type) (see ‘Improving outcomes for people with skin tumours including melanoma’ [NICE cancer service guidance])


• people with lighter skin types, such as skin types I or II on the Fitzpatrick scale


• people who are likely to require ciclosporin or long-term methotrexate


• young people.

12.Offer lifetime skin cancer surveillance to people treated with PUVA who have:

• had more than 150 PUVA treatments or


• developed skin cancer.

13.Ensure that a permanent record of the person’s cumulative number of UV treatments is kept (for example, in a national record.

14.Do not use PUVA when other appropriate treatments are available in:

• people with a personal history of skin cancer or


• people who have already received 150 PUVA treatments or

15. Use PUVA with caution or consider other treatment options in:

• people at risk of skin cancer (melanoma and non-melanoma type) (see ‘Improving outcomes for people with skin tumours including melanoma’

• people with lighter skin types, such as skin types I or II on the Fitzpatrick scale


• people who are likely to require ciclosporin or long-term methotrexate


• young people.

16.Offer lifetime skin cancer surveillance to people treated with PUVA who have:

• had more than 150 PUVA treatments or


• developed skin cancer.

Recommendations for Systemic therapy

General recommendations

1. Responsibility for use of systemic therapy should be in specialist settings only. Certain aspects of supervision and monitoring may be delegated to other healthcare professionals and completed in non-specialist settings, in which case, such arrangements should be formalised.

2.When offering systemic therapy, tailor the choice of agent and dosing schedule to the needs of the individual and include consideration of:

• the person’s age


• disease phenotype, pattern of activity and previous treatment history


• disease severity and impact


• the presence of psoriatic arthritis (in consultation with a rheumatologist)


• conception plans


• comorbidities


• the person’s views.

3.Be aware of the benefits of, contraindications to and adverse effects associated with systemic treatments. Explain the risks and benefits to people undergoing this treatment (and their families or carers where appropriate), using absolute risks and natural frequencies when possible. Support and advice should be provided by healthcare professionals who are trained and competent in the use of systemic therapies.

4.When reviewing response to systemic therapy, take into account:

• disease severity compared with baseline (for example, PASI baseline to endpoint score)


• control of psoriatic arthritis disease activity (in consultation with a rheumatologist if necessary)


• the impact of the disease on the person’s physical, psychological and social wellbeing


• the benefits versus the risks of continued treatment


• the views of the person undergoing treatment (and their family or carers where appropriate).

5.Monitor people using systemic treatment for all types of psoriasis in accordance with national and local drug guidelines and policy. Take appropriate action in the event of laboratory abnormalities or adverse events.

6.Offer adjunctive topical therapy to people with psoriasis using systemic therapy to optimise treatment outcomes.

7..Offer people with psoriasis who are starting treatment with a systemic non-biological or biological drug the opportunity to participate in long-term safety registries (for example the British Association of Dermatologists Biologic Interventions Register).

Systemic non-biological therapy

8.Offer systemic non-biological therapy to people with any type of psoriasis if:

• it cannot be controlled with topical therapy and


• it has a significant impact on physical, psychological or social wellbeing and


• one or more of the following apply:psoriasis is extensive (for example, more than 10% of body surface area affected or a Psoriasis Area and Severity Index (PASI) score of more than 10) or

• psoriasis is localised and associated with significant functional impairment and/or high levels of distress (for example severe nail disease or involvement at high-impact sites) o


• phototherapy has been ineffective, cannot be used or has resulted in rapid relapse (rapid relapse is defined as greater than 50% of baseline disease severity within 3 months).

Choice of drugs

9. Offer methotrexate as the first choice of systemic agent for people with psoriasis who fulfil the criteria for systemic therapy.

10. In people with both active psoriatic arthritis and any type of psoriasis that fulfils the criteria for systemic therapy (see recommendation 81) consider the choice of systemic agent in consultation with a rheumatologist.

11. Offer ciclospori as the first choice of systemic agent for people who fulfil the criteria for systemic therapy (see recommendation 81) and who:

• need rapid or short-term disease control (for example a psoriasis flare) or


• have palmoplantar pustulosis or


• are considering conception (both men and women) and systemic therapy cannot be avoided.

12.Consider changing from methotrexate to ciclosporin (or vice-versa) when response to the first-choice systemic treatment is inadequate.

13.Consider acitretin for adults, and in exceptional cases only for children and young people, in the following circumstances:

• if methotrexate and ciclosporin are not appropriate or have failed or


• for people with pustular forms of psoriasis.

Drug regimens

14.Use incremental dosing of methotrexate (for example, starting with an initial dose of 5–10 mg once a week) and gradually increase up to an effective dose and a maximum of 25 mg a week. Assess the treatment response after 3 months at the target dose of methotrexate and stop treatment if the response is inadequate (for example, a decrease of less than 75% in PASI score or a decrease of less than 50% in PASI score and 5 points in DLQI score).

15.Use the lowest possible therapeutic dose of methotrexate to maintain remission.

16.Use 2.5–3 mg/kg a day of ciclosporin. Escalate to 5 mg/kg a day after 4 weeks only when there is no response to the lower dose or when rapid disease control is necessary (for example in severe unstable disease). Assess the treatment response after 3 months at the optimum dose of ciclosporin and stop treatment if the response is inadequate (for example, less than a 75% decrease in PASI score or less than a 50% decrease in PASI score and less than 5 points in DLQI score).

17.Use the lowest possible therapeutic dose of ciclosporin to maintain remission for up to 1 year. Consider other treatment options when disease relapses rapidly on stopping ciclosporin therapy (rapid relapse is defined as greater than 50% of baseline disease severity within 3 months of stopping treatment). Do not use ciclosporin continuously for more than 1 year unless disease is severe or unstable and other treatment options, including systemic biological therapy, cannot be used.

18.Use incremental dosing of acitretin to minimise mucocutaneous side effects and achieve a target dose of 25 mg daily in adults. Consider dose escalation to a maximum of 50 mg daily when no other treatment options are available. Assess the treatment response after 4 months at the optimum dose of acitretin and stop treatment if the response is inadequate, for example:

• in plaque-type psoriasis, less than a 75% decrease in PASI score or less than a 50% decrease in PASI score and less than 5 points in DLQI score


• in pustular forms of psoriasis, not achieving clear or nearly clear on the static Physician’s Global Assessment.

Methotrexate and risk of hepatotoxicity

19. When considering the risks and benefits of treating any type of psoriasis with methotrexate, be aware that methotrexate can cause a clinically significant rise in transaminases and that long-term therapy may be associated with liver fibrosis .

Methotrexate and monitoring for hepatotoxicity

20.Before and during methotrexate treatment, offer the person with any type of psoriasis an evaluation for potential risk of hepatotoxicity. Use standard liver function tests and serial serum procollagen III levels to monitor for abnormalities during treatment with methotrexate, taking into account pre-existing risk factors (for example obesity, diabetes and alcohol use), baseline results and trends over time.

21.When using serum procollagen III levels to exclude liver fibrosis or cirrhosis, be aware that the:

• test cannot be used in children and young people


• results may be unreliable in people with psoriatic arthritis


• estimated positive predictive value is 23–95% and the estimated negative predictive value is 89–100%.

22. Provide advice on modifiable risk factors for liver disease prior to and during therapy, including alcohol intake and weight reduction.

23. Seek timely specialist advice and consider referral to a clinician with expertise in liver disease if the results of liver tests are abnormal.

Systemic biological therapy

The GDG did not review evidence for any aspect of the use of a first biological agent as guidance on this is already available in the existing NICE technology appraisals. Recommendations 99–107 are replicated from the relevant TAs and are listed here in alphabetical order by drug.

24.Biological agents for psoriasis should be initiated and supervised only by specialist physicians experienced in the diagnosis and treatment of psoriasis.

25.If a person has both psoriasis and psoriatic arthritis, take into account both conditions before initiating or making changes to biological therapy and manage their treatment in consultation with a rheumatologist (see also ‘Etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis’ [NICE technology appraisal guidance 199] and ‘Golimumab for the treatment of psoriatic arthritis’ ).

26.When using the DLQI, healthcare professionals should take into account any physical, sensory or learning disabilities, or communication difficulties that could affect the responses to the DLQI and make any adjustments they consider appropriate.

Adalimumab

The recommendations in this section are from Adalimumab for the treatment of adults with psoriasis (NICE technology appraisal guidance 146).

27.Adalimumab is recommended as a treatment option for adults with plaque psoriasis for whom anti-tumor necrosis factor (TNF) treatment is being considered and when the following criteria are both met.

• The disease is severe as defined by a total PASI of 10 or more and a DLQI of more than 10.


• Psoriasis has not responded to standard systemic therapies including ciclosporin, methotrexate and PUVA; or the person is intolerant of, or has a contraindication to, these treatments.

28.Adalimumab should be discontinued in people whose psoriasis has not responded adequately at 16 weeks. An adequate response is defined as either:

• a 75% reduction in the PASI score (PASI 75) from when treatment started or


• a 50% reduction in the PASI score (PASI 50) and a five-point reduction in DLQI from start of treatment.

Etanercept

The recommendations in this section are from Etanercept and efalizumab for the treatment of adults with psoriasis (NICE technology appraisal guidance 103).

29.Etanercept, within its licensed indications, administered at a dose not exceeding 25 mg twice weekly is recommended for the treatment of adults with plaque psoriasis only when the following criteria are met.

• The disease is severe as defined by a total PASI of 10 or more and a DLQI of more than 10.


• The psoriasis has failed to respond to standard systemic therapies including ciclosporin, methotrexate and PUVA; or the person is intolerant to, or has a contraindication to, these treatments.

30.Etanercept treatment should be discontinued in patients whose psoriasis has not responded adequately at 12 weeks. Further treatment cycles are not recommended in these patients. An adequate response is defined as either:

• a 75% reduction in the PASI score from when treatment started (PASI 75) or


• a 50% reduction in the PASI score (PASI 50) and a five-point reduction in DLQI from when treatment started.

Infliximab

The recommendations in this section are from Infliximab for the treatment of adults with psoriasis (NICE technology appraisal guidance 134).

31.Infliximab, within its licensed indications, is recommended as a treatment option for adults with plaque psoriasis only when the following criteria are met.

• The disease is very severe as defined by a total PASI of 20 or more and a DLQI of more than 18.


• The psoriasis has failed to respond to standard systemic therapies such as ciclosporin, methotrexateor PUVA, or the person is intolerant to or has a contraindication to these treatments.

32.Infliximab treatment should be continued beyond 10 weeks only in people whose psoriasis has shown an adequate response to treatment within 10 weeks. An adequate response is defined as either:

• a 75% reduction in the PASI score from when treatment started (PASI 75) or


• a 50% reduction in the PASI score (PASI 50) and a five-point reduction in the DLQI from when treatment started.

Ustekinumab

The recommendations in this section are from Ustekinumab for the treatment of adults with moderate to severe psoriasis (NICE technology appraisal guidance 180).

33.Ustekinumab is recommended as a treatment option for adults with plaque psoriasis when the following criteria are met.

• The disease is severe, as defined by a total PASI score of 10 or more and a DLQI score of more than 10.


• The psoriasis has not responded to standard systemic therapies, including ciclosporin, methotrexate and PUVA, or the person is intolerant of or has a contraindication to these treatments.


• The manufacturer provides the 90 mg dose (two 45 mg vials) for people who weigh more than 100 kg at the same total cost as for a single 45 mg vial.

34.Ustekinumab treatment should be stopped in people whose psoriasis has not responded adequately by 16 weeks after starting treatment. An adequate response is defined as either:

• a 75% reduction in the PASI score (PASI 75) from when treatment started or


• a 50% reduction in the PASI score (PASI 50) and a five-point reduction in the DLQI score from when treatment started.

Changing to an alternative biological drug

36.Consider changing to an alternative biological drug in adults if:

• the psoriasis does not respond adequately to a first biological drug as defined in NICE technology appraisals at 10 weeks after starting treatment for infliximab, 12 weeks for etanercept, and 16 weeks for adalimumab and ustekinumab; primary failure) or


• the psoriasis initially responds adequately but subsequently loses this response, (secondary failure) or


• the first biological drug cannot be tolerated or becomes contraindicated.

37. For adults in whom there is an inadequate response to a second biological drug, seek supra-specialist advice from a clinician with expertise in biological therapy.

For reference log on to https://www.ncbi.nlm.nih.gov/books/NBK327715/#