Fast Five Quiz: Severe Psoriasis

Dirk M. Elston, MD; William D. James, MD


December 20, 2021

According to the British Association of Dermatologists 2020 guidelines for biologic therapy, biologic therapy may be offered to people with psoriasis who require systemic therapy if methotrexate and cyclosporine have failed; if these agents are not tolerated or are contraindicated; and if the psoriasis has a significant impact on physical, psychological, or social functioning (eg, Dermatology Life Quality Index [DLQI] or Children's DLQI score greater than 10 or clinically relevant depressive or anxiety symptoms).

One or more of the following disease severity criteria must also apply:

  • Extensive psoriasis (defined as BSA > 10% or Psoriasis Area and Severity Index ≥ 10)

  • Severe psoriasis at localized sites and associated with significant functional impairment and/or high levels of distress (eg, nail disease or involvement of high-impact and difficult-to-treat sites, such as the face, scalp, palms, soles, flexures, and genitals)

Biologic therapy should also be considered earlier in the treatment plan (eg, if methotrexate has failed, is not tolerated, or is contraindicated) in people with psoriasis who fulfill the disease severity criteria and who also have active psoriatic arthritis or who have psoriasis that is persistent while not on a therapy that cannot be continued in the long term (eg, narrow-band UVB light).

In general, biologic therapy can be started 4 weeks after the administration of a live vaccine. Biologic therapy should be stopped for at least 6 months before giving live vaccines; in the case of the herpes zoster (shingles) vaccine, it should be stopped for 12 months.

As noted above, the presence of active psoriatic arthritis is a consideration for the initiation of biologic therapy; however, it is not the only consideration and should always be taken into account with other objective and subjective measures of disease severity.

Learn more about biologic therapy for severe psoriasis.


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