Table Info

Table 2.

Recommendations according to comorbidities in patients with psoriasis

Comorbidities	Strong recommendation in favour (Will likely be beneficial)	Weak recommendation in favour (Might be beneficial)	No recommendation (Insufficient evidence)	Weak recommendation against (Will likely not help but cause no harm)	Strong recommendation against (Likely to cause harm)
Psoriatic arthritis	MTX	Cyclosporin	Acitretin, fumarates	-	-
Chronic inflammatory bowel disease: Crohn’s disease	-	Acitretin (especially cases with mild paradoxical psoriasis), MTX	Cyclosporin, fumarates	-	-
Chronic inflammatory bowel disease: ulcerative colitis	-	Acitretin (especially cases with mild paradoxical psoriasis), cyclosporin (2nd choice oral treatment)	MTX, fumarates	-	-
Psychiatric disorders	MTX, acitretin, cyclosporin, fumarates	-	-	-	-
Metabolic syndrome	Fumarates	Acitretin, cyclosporin, MTX	-	-	-
Diabetes mellitus/insulin resistance	Acitretin, fumarates	Cyclosporin, MTX	-	-	-
Dyslipidaemia	-	-	MTX, cyclosporin, fumarates	Acitretin	-
Obesity	Fumarates	-	-	Acitretin, cyclosporin, MTX	-
Cardiovascular risk factors	MTX, fumarates	-	-	Acitretin, cyclosporin	-
Advanced heart failure	-	Acitretin, MTX	Fumarates	Cyclosporin	-
Ischemic heart disease	-	MTX	Fumarates	Acitretin, cyclosporin	-
Cancer history	-	Acitretin, MTX	Fumarates	Cyclosporin	-
Chronic kidney disease	Stage 1/2 renal insufficiency: use MTX with standard dose	Mild-moderate renal impairment (eGFR ≥ 30 mL/min per 1.73 m²). Acitretin, MTX, fumarates (carefull dosing/reduced dose)	-	-	Severe renal impairment (eGFR < 30 mL/min per 1.73 m²), cyclosporin, MTX, fumarates
Demyelinating diseases	Fumarates	MTX	Cyclosporin	Acitretin	-
Concomitant treated tuberculosis	-	Acitretin, fumarates	Cyclosporin, MTX	-	-
Latent tuberculosis	-	Acitretin, fumarates	-	Cyclosporin, MTX	-
HIV with undetectable viral load	-	Acitretin	-	Cyclosporin, MTX, fumarates	-
HIV with detectable viral load	-	Acitretin	-	-	Cyclosporin, MTX, fumarates
Hepatitis C	-	-	Fumarates	Cyclosporin	Acitretin, MTX
Hepatitis B	-	Acitretin, cyclosporin	Fumarates	-	MTX
Solid cancer	-	Acitretin, MTX, cyclosporin, fumarates	-	-	-
Hematological cancer	-	Acitretin, MTX, fumarates	Cyclosporin	-	-
Non-melanoma skin cancer	Acitretin	Fumarates	-	Cyclosporin, MTX	-
Melanoma	-	Acitretin, MTX, fumarates	-	-	Cyclosporin

eGFR: estimated glomerular filtration rate

Declarations

Author contributions

SA: Conceptualization, Writing—original draft, Writing—review & editing.

Conflicts of interest

The author declares there is no conflicts of interest.

Ethical approval

Not applicable.

Consent to participate

Not applicable.

Consent to publication

Not applicable.

Availability of data and materials

Not applicable.

Funding

Not applicable.

Copyright

References

Langley RG, Krueger GG, Griffiths CE. Psoriasis: epidemiology, clinical features, and quality of life. Ann Rheum Dis. 2005;64 Suppl 2:ii18–23. [DOI] [PubMed] [PMC]

Myers WA, Gottlieb AB, Mease P. Psoriasis and psoriatic arthritis: clinical features and disease mechanisms. Clin Dermatol. 2006;24:438–47. [DOI] [PubMed]

Ibrahim S, Amer A, Nofal H, Abdellatif A. Practical compendium for psoriasis management. Dermatol Ther. 2020;33:e13243. [DOI] [PubMed]

Korman NJ. Management of psoriasis as a systemic disease: what is the evidence? Br J Dermatol. 2020;182:840–8. [DOI] [PubMed] [PMC]

Nast A, Amelunxen L, Augustin M, Boehncke WH, Dressler C, Gaskins M, et al. S3 Guideline for the treatment of psoriasis vulgaris, update – short version part 1 – systemic treatment. J Dtsch Dermatol Ges. 2018;16:645–69. [DOI] [PubMed]

Nast A, Smith C, Spuls PI, Avila Valle G, Bata-Csörgö Z, Boonen H, et al. EuroGuiDerm Guideline on the systemic treatment of Psoriasis vulgaris – part 1: treatment and monitoring recommendations. J Eur Acad Dermatol Venereol. 2020;34:2461–98. [DOI] [PubMed]

Menter A, Gelfand JM, Connor C, Armstrong AW, Cordoro KM, Davis DMR, et al. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management of psoriasis with systemic nonbiologic therapies. J Am Acad Dermatol. 2020;82:1445–86. [DOI] [PubMed]

Chat VS, Uppal SK, Kearns DG, Han G, Wu JJ. Translating the 2020 AAD-NPF guidelines of care for the management of psoriasis with systemic nonbiologics to clinical practice. Cutis. 2021;107:99–103. [DOI] [PubMed]

Kolios AG, Yawalkar N, Anliker M, Boehncke WH, Borradori L, Conrad C, et al. Swiss S1 guidelines on the systemic treatment of psoriasis vulgaris. Dermatology. 2016;232:385–406. [DOI] [PubMed]

10.

Mason KJ, Williams S, Yiu ZZN, McElhone K, Ashcroft DM, Kleyn CE, et al. Persistence and effectiveness of nonbiologic systemic therapies for moderate-to-severe psoriasis in adults: a systematic review. Br J Dermatol. 2019;181:256–64. [DOI] [PubMed] [PMC]

11.

Strober B, Ryan C, van de Kerkhof P, van der Walt J, Kimball AB, Barker J, et al.; International Psoriasis Council Board Members and Councilors. Recategorization of psoriasis severity: Delphi consensus from the International Psoriasis Council. J Am Acad Dermatol. 2020;82:117–22. [DOI] [PubMed]

12.

Alabas OA, Mason KJ, Yiu ZZN, Hampton PJ, Reynolds NJ, Owen CM, et al.; BADBIR Study Group. Effectiveness and persistence of acitretin, ciclosporin, fumaric acid esters and methotrexate for patients with moderate-to-severe psoriasis: a cohort study from BADBIR. Br J Dermatol. 2023;188:618–27. [DOI] [PubMed]

13.

Carrascosa JM, de la Cueva P, Ara M, Puig L, Bordas X, Carretero G, et al. Methotrexate in moderate to severe psoriasis: review of the literature and expert recommendations. Actas Dermosifiliogr. 2016;107:194–206. English, Spanish. [DOI] [PubMed]

14.

Lindqvist T, Salah LA, Gillstedt M, Wennberg AM, Osmancevic A. Methotrexate management in psoriasis: are we following the guidelines? Acta Derm Venereol. 2018;98:449–51. [DOI] [PubMed]

15.

Leung YY, Korotaeva TV, Candia L, Pedersen SJ, Bautista Molano W, Ruderman EM, et al. Management of peripheral arthritis in patients with psoriatic arthritis: an updated literature review informing the 2021 GRAPPA treatment recommendations. J Rheumatol. 2023;50:119–30. Erratum in: J Rheumatol. 2022;49:1. [DOI] [PubMed]

16.

Lambert JLW, Segaert S, Ghislain PD, Hillary T, Nikkels A, Willaert F, et al. Practical recommendations for systemic treatment in psoriasis according to age, pregnancy, metabolic syndrome, mental health, psoriasis subtype and treatment history (BETA-PSO: belgian evidence-based treatment advice in psoriasis; part 1). J Eur Acad Dermatol Venereol. 2020;34:1654–65. [DOI] [PubMed] [PMC]

17.

Lambert JLW, Segaert S, Ghislain PD, Hillary T, Nikkels A, Willaert F, et al. Practical recommendations for systemic treatment in psoriasis in case of coexisting inflammatory, neurologic, infectious or malignant disorders (BETA-PSO: belgian evidence-based treatment advice in psoriasis; part 2). J Eur Acad Dermatol Venereol. 2020;34:1914–23. [DOI] [PubMed] [PMC]

18.

Nast A, Smith C, Spuls PI, Avila Valle G, Bata-Csörgö Z, Boonen H, et al. EuroGuiDerm Guideline on the systemic treatment of psoriasis vulgaris – part 2: specific clinical and comorbid situations. J Eur Acad Dermatol Venereol. 2021;35:281–317. [DOI] [PubMed]

19.

Amatore F, Villani AP, Tauber M, Viguier M, Guillot B; Psoriasis Research Group of the French Society of Dermatology (Groupe de Recherche sur le Psoriasis de la Société Française de Dermatologie). French guidelines on the use of systemic treatments for moderate-to-severe psoriasis in adults. J Eur Acad Dermatol Venereol. 2019;33:464–83. [DOI] [PubMed] [PMC]

20.

Booij MT, Van De Kerkhof PC. Acitretin revisited in the era of biologics. J Dermatolog Treat. 2011;22:86–9. [DOI] [PubMed]

21.

Dogra S, Yadav S. Acitretin in psoriasis: an evolving scenario. Int J Dermatol. 2014;53:525–38. [DOI] [PubMed]

22.

Carretero G, Ribera M, Belinchón I, Carrascosa JM, Puig L, Ferrandiz C, et al.; Psoriasis Group of the AEDV. Guidelines for the use of acitretin in psoriasis. Psoriasis group of the Spanish Academy of Dermatology and venereology. Actas Dermosifiliogr. 2013;104:598–616. [DOI] [PubMed]

23.

Chiricozzi A, Panduri S, Dini V, Tonini A, Gualtieri B, Romanelli M. Optimizing acitretin use in patients with plaque psoriasis. Dermatol Ther. 2017;30:e12453. [DOI] [PubMed]

24.

Shah S, Nikam B, Kale M, Jamale V, Chavan D. Safety and efficacy profile of oral cyclosporine vs oral methotrexate vs oral acitretin in palmoplantar psoriasis: a hospital based prospective investigator blind randomized controlled comparative study. Dermatol Ther. 2021;34:e14650. [DOI] [PubMed]

25.

Graceffa D, Bonifati C, Pacifico A, Morrone A. When the old works better than the new: a case of severe nail psoriasis successfully treated with acitretin after failure of two biologic regimens. Dermatol Ther. 2020;33:e13615. [DOI] [PubMed]

26.

Dogra S, Jain A, Kanwar AJ. Efficacy and safety of acitretin in three fixed doses of 25, 35 and 50 mg in adult patients with severe plaque type psoriasis: a randomized, double blind, parallel group, dose ranging study. J Eur Acad Dermatol Venereol. 2013;27:e305–11. [DOI] [PubMed]

27.

Kara Polat A, Oguz Topal I, Aslan Kayıran M, Koku Aksu AE, Aytekin S, Topaloglu Demir F, et al. Drug survival and safety profile of acitretin monotherapy in patients with psoriasis: a multicenter retrospective study. Dermatol Ther. 2021;34:e14834. [DOI] [PubMed]

28.

Chularojanamontri L, Silpa-Archa N, Wongpraparut C, Limphoka P. Long-term safety and drug survival of acitretin in psoriasis: a retrospective observational study. Int J Dermatol. 2019;58:593–9. [DOI] [PubMed]

29.

Çalıskan E, Tunca M, Açıkgöz G, Arca E, Yürekli A, Akar A. Narrow band ultraviolet-B versus Goeckerman therapy for psoriasis with and without acitretin: a retrospective study. Indian J Dermatol Venereol Leprol. 2015;81:584–7. [DOI] [PubMed]

30.

Polat Ekinci A, Bölük KN, Babuna Kobaner G. Secukinumab and acitretin as a combination therapy for three clinical forms of severe psoriasis in multi-drug refractory patients: a case series of high efficacy and safety profile. Dermatol Ther. 2021;34:e14704. [DOI] [PubMed]

31.

Oh EH, Koh WS, Shin JM, Kim JE, Ko JY, Ro YS. Clinical experience of cyclosporin treatment in patients with psoriasis and psoriatic arthritis. J Dermatol. 2018;45:329–30. [DOI] [PubMed] [PMC]

32.

Marsili F, Travaglini M, Stinco G, Manzoni R, Tiberio R, Prignano F, et al. Effectiveness of cyclosporine A in patients with moderate to severe plaque psoriasis in a real-life clinical setting in Italy: the TRANSITION study. J Dermatolog Treat. 2022;33:401–7. [DOI] [PubMed]

33.

Berry W, Daniel BS, Baker C, Foley P. Real world experience using Ciclosporin in psoriasis: efficacy and toxicity in the Australasian Psoriasis Registry. Australas J Dermatol. 2020;61:380–2. [DOI] [PubMed]

34.

Amber T, Tabassum S. Cyclosporin in dermatology: a practical compendium. Dermatol Ther. 2020;33:e13934. [DOI] [PubMed]

35.

Maza A, Montaudié H, Sbidian E, Gallini A, Aractingi S, Aubin F, et al. Oral cyclosporin in psoriasis: a systematic review on treatment modalities, risk of kidney toxicity and evidence for use in non-plaque psoriasis. J Eur Acad Dermatol Venereol. 2011;25 Suppl 2:19–27. [DOI] [PubMed]

36.

Borghi A, Corazza M, Mantovani L, Bertoldi AM, Giari S, Virgili A. Prolonged cyclosporine treatment of severe or recalcitrant psoriasis: descriptive study in a series of 20 patients. Int J Dermatol. 2012;51:1512–6. [DOI] [PubMed]

37.

Kothari R, Mitra D, Valarmathi T, Kishore K, Bhatnagar A. Successful treatment of recalcitrant facial sebopsoriasis with low-dose cyclosporine. Dermatol Ther. 2022;35:e15614. [DOI] [PubMed]

38.

Shi L, Lian N, Liu L, Chen M. Tapering and discontinuation of systemic medications in psoriasis patients with low disease activity. Dermatol Ther. 2020;33:e13599. [DOI] [PubMed]

39.

Masson Regnault M, Shourick J, Jendoubi F, Tauber M, Paul C. Time to relapse after discontinuing systemic treatment for psoriasis: a systematic review. Am J Clin Dermatol. 2022;23:433–47. [DOI] [PubMed] [PMC]

40.

Feltes F, Macías del Toro E, Ramírez Bellver JL, Bernardez Guerra C. Weekend ciclosporin maintenance therapy for moderate psoriasis. Actas Dermosifiliogr. 2015;106:583–4. English, Spanish. [DOI] [PubMed]

41.

Smith D. Fumaric acid esters for psoriasis: a systematic review. Ir J Med Sci. 2017;186:161–77. [DOI] [PubMed]

42.

Pezzolo E, Cazzaniga S, Di Leo S, Naldi L; PsoReal Study Group. Efficacy and safety of dimethyl fumarate in comparison with conventional therapy for psoriasis: an Italian real-world clinical experience. J Eur Acad Dermatol Venereol. 2022;36:e534–7. [DOI] [PubMed]

43.

Mrowietz U, Barker J, Boehncke WH, Iversen L, Kirby B, Naldi L, et al. Clinical use of dimethyl fumarate in moderate-to-severe plaque-type psoriasis: a European expert consensus. J Eur Acad Dermatol Venereol. 2018;32 Suppl 3:3–14. [DOI] [PubMed]

44.

von Kiedrowski R, Diemert S. Introducing a simplified titration scheme for dimethylfumarate (DMF) in patients with moderate-to-severe psoriasis: a case series. J Dermatolog Treat. 2022;33:2376–9. [DOI] [PubMed]

45.

Termeer C, Reinhold U, Dirschka T, von Kiedrowski R, Kurzen H. Long-term use of fumaric acid esters for the treatment of psoriasis in daily practice. J Dermatolog Treat. 2021;32:610–6. [DOI] [PubMed]

46.

Augustin M, Landeck L, Diemert S, Asadullah K, Hammann U, Ertner K, et al. Long-term treatment with dimethyl fumarate for plaque psoriasis in routine practice: good overall effectiveness and positive effect on impactful areas. Dermatol Ther (Heidelb). 2022;12:1121–31. [DOI] [PubMed] [PMC]

47.

Pellacani G, Bigi L, Parodi A, Burlando M, Lanna C, Campione E, et al. Efficacy and safety of dimethyl fumarate in patients with moderate-to-severe plaque psoriasis: DIMESKIN-2, a multicentre single-arm phase IIIb study. J Clin Med. 2022;11:4778. [DOI] [PubMed] [PMC]

48.

D’Souza LS, Payette MJ. Estimated cost efficacy of systemic treatments that are approved by the US Food and Drug Administration for the treatment of moderate to severe psoriasis. J Am Acad Dermatol. 2015;72:589–98. [DOI] [PubMed]