The National Psoriasis Foundation Medical Board reviewed and updated the Canadian Guidelines for the Management of Plaque Psoriasis to include new treatments such as ustekinumab and excimer laser, according to a Consensus Statement published in the January issue of the Archives of Dermatology.

-Team@CMHF

• The manifestations of psoriasis can be severe and widespread with signs and symptoms that greatly affect the patients’ quality of life.
• Psoriatic arthritis, which can be severe and debilitating, is also present in many patients.
• Finally, psoriasis is associated with an increased risk of serious comorbidities, such as cardiovascular disease and the metabolic syndrome that complicate management and increase the risk of early death.
• The new recommendations cover management of psoriasis in special populations, including children, pregnant women with psoriasis, pregnant partners of patients with psoriasis, nursing mothers, the elderly, patients infected with hepatitis B or C virus or with HIV, and patients with malignant neoplasms.
• Treatments covered in the guidelines include newly approved biological agents such as ustekinumab; the excimer laser, which is approved for psoriasis treatment in the United States; and tumor necrosis factor (TNF) blockers.
• The consensus statement also describes management of psoriasis therapies in conjunction with elective surgery and vaccinations.

• Drugs used in management of psoriasis include the following:
  1. Etanercept, a TNF inhibitor, is often used as a first-line systemic drug for chronic plaque psoriasis
  2. Ustekinumab, a monoclonal antibody that binds the shared p40 protein subunit of interleukin (IL) 12 and IL-23, which has efficacy and safety comparable to those of etanercept and may be used as first-line systemic treatment for chronic plaque psoriasis
  3. Adalimumab, a TNF inhibitor, which may be used as first-line systemic treatment of plaque psoriasis and is more effective and has a lower rate of adverse effects than methotrexate
  4. Cyclosporine, a fast-acting systemic oral calcineurin inhibitor, which is often used as a first-line therapy for von Zumbusch for pustular psoriasis or erythrodermic psoriasis, and may also be used intermittently for up to 12 weeks to control a psoriasis flare
  5. Methotrexate, a sodium inhibitor of folate biosynthesis, which may be used as a first-line systemic drug for plaque psoriasis and is somewhat less effective than cyclosporine, but may be used continuously for decades if needed;
  6. Alefacept, which triggers the death of pathogenic T lymphocytes and may be used intermittently; although there is little evidence to support its use to achieve full clearance, it is often used in combination regimens and may be used as a first-line systemic drug for chronic plaque psoriasis;
  7. Infliximab, an intravenously administered TNF inhibitor, which is often used as a second- or third-line biological for chronic plaque psoriasis
  8. Acitretin, an oral retinoid, which is used as first-line systemic therapy for chronic palmoplantar or pustular psoriasis in patients of non-childbearing potential; however, it is of limited benefit for plaque psoriasis.
• Ultraviolet (UV) light therapies include narrowband UV-B and psoralen-UV-A, which are effective and rapidly deplete cell populations implicated in psoriasis pathogenesis.
• However, adverse effects may include erythema, blistering, skin aging, and risk for carcinogenesis.
• The excimer laser emits monochromatic 308-nm radiation, which is similarly effective to those of narrowband UV-B, but with fewer adverse effects (erythema and transient hyperpigmentation). Exposure can be restricted to psoriatic skin.
• Advances in psoriasis research continue to yield new approaches that promise ever more control of plaque psoriasis
• The developments may well revolutionize care in coming years; however they are unlikely to change the fundamental need for active engagement with the patient to ensure that the selected treatment is used appropriately.

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http://www.medscape.com/viewarticle/757223