AAD and NPF Guidelines

Introduction

The current guidelines on the use of biologic agents for the treatment of psoriasis were jointly released in 2019 Joint American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) Guidelines for the Treatment of Psoriasis with Biologics. Separate recommendations are provided for each biologic agent, including:

• Etanercept: Recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis, including that affecting the scalp, nails, and other subtypes (pustular or erythrodermic) of moderate-to-severe plaque psoriasis. Etanercept is also recommended for the treatment of psoriasis of any severity when associated with significant PsA. A combination of etanercept and topical agents or etanercept and methotrexate is recommended to augment the treatment efficacy in moderate-to-severe plaque psoriasis. The guidelines also state that etanercept may be combined with apremilast, acitretin, cyclosporine (see Chapter 11), or narrowband UVB therapy to improve efficacy of psoriasis treatment.
• Infliximab: Recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis. Infliximab is also recommended for the treatment of psoriasis of any severity when associated with significant PsA. The guidelines also state that infliximab can be recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis affecting the palms and soles (plaque-type palmoplantar psoriasis), or that affecting the nails or the scalp. It may be recommended for the treatment of other subtypes (pustular or erythrodermic) of moderate-to-severe plaque psoriasis in adult patients. A combination of infliximab and topical agents can be recommended to augment efficacy for the treatment of moderate-to-severe plaque psoriasis, and combinations with other agents (including acitretin, methotrexate, and apremilast) may be recommended to improve efficacy as well.
• Adalimumab: Recommended as a monotherapy treatment option for adult patients with moderate-to-severe plaque psoriasis, including that affecting the nails and palmoplantar psoriasis. Adalimumab is also recommended for the treatment of psoriasis of any severity when associated with significant PsA. The guidelines further state that adalimumab can be recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis affecting the scalp and with other subtypes (pustular or erythrodermic) of moderate-to-severe psoriasis. A combination of adalimumab and topical agents (see Chapter 9) can be recommended to augment efficacy for the treatment of moderate-to-severe plaque psoriasis. Combinations with nonbiologic systemic agents (including acitretin, methotrexate, cyclosporine, and apremilast) or narrowband UVB therapy may also be recommended.
• Ustekinumab: Recommended as a monotherapy treatment option for use in adult patients with moderate-to-severe plaque psoriasis. Ustekinumab can be used as a monotherapy for adult patients with moderate-to-severe plaque psoriasis affecting the nails, the scalp, and plaque type palmoplantar psoriasis. Ustekinumab is also recommended for the treatment of psoriasis of any severity when associated with significant PsA. To augment efficacy for the treatment of moderate-to-severe plaque psoriasis, ustekinumab may also be combined with topicals, nonbiologic systemic agents including apremilast, methotrexate, acitretin, and cyclosporine, and narrowband UVB therapy.
• Secukinumab: Recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis, including that affecting the nails and palmoplantar plaque psoriasis. Secukinumab can be recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis affecting the head and neck, including the scalp, as well as in adult patients with moderate-to-severe palmoplantar pustulosis, and those with erythrodermic psoriasis. It may be used in patients with plaque psoriasis when associated with PsA.
• Ixekizumab: Recommended as a monotherapy treatment option for use in adult patients with moderate-to-severe plaque psoriasis, and in adult patients with plaque psoriasis of any severity when associated with PsA. Ixekizumab can also be recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis affecting the scalp or the nails, as well as adult patients with erythrodermic psoriasis and those with generalized pustular psoriasis.
• Brodalumab: Recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis. Brodalumab can also be used as a monotherapy in adult patients with generalized pustular psoriasis.
• Guselkumab: Recommended as a monotherapy treatment option for use in adult patients with moderate-to-severe plaque psoriasis and in adult patients with scalp, nail, and plaque-type palmoplantar psoriasis.
• Tildrakizumab: Recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis.
• Risankizumab: The current AAD-NPF guidelines pre-date the approval of risankizumab, but state that it can be used as monotherapy in adult patients with moderate-to-severe plaque psoriasis.

More information and further recommendations can be found in the current AAD-NPF Guidelines.