Topical Cycling: The Obstacles to Moving Forward with Systemic Psoriasis Therapies and How to Characterize the Systemic Ready Patient

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Milaan Shah
Lauren Miller
Robert Casquejo
TJ Chao
Douglas DiRugierro
Kirk Gautier
Holly Glover
Kristine Kucera
Andrea Nguyen
Leigh Ann Pansch
Joleen Volz
Melodie S. Young
Joshua Burshtein
Danny Zakria


psoriasis, psoriatic arthritis, topicals, systemics, expert panel, topical failure


Background: Psoriasis is a chronic, inflammatory disease with numerous negative physical and psychosocial impacts. Topicals are a mainstay of treatment, particularly for disease with minimal skin involvement, but they are limited due to an inability to target systemic symptoms and a lack of convenience, patient adherence, and patient satisfaction. Given its systemic implications, many patients with psoriasis are undertreated including those with limited body surface area (BSA) involvement. With a growing role in providing dermatological services, physician assistants and nurse practitioners can benefit from additional guidance on how to appropriately treat these patients, as the current clinical recommendations require further expansion, and the criteria for what qualifies as adequate treatment and response are incomplete.

Methods: Two comprehensive literature searches of PubMed, Scopus, and Google Scholar were completed for English-language original research articles on the use of topical versus systemic medications for psoriasis and its comorbidities. A panel of 11 dermatology physician assistants and nurse practitioners with expertise in managing psoriatic disease gathered to review the selected literature and form consensus statements with clinical recommendations for treating psoriasis. A modified Delphi process was employed to approve each statement and a strength of recommendation was assigned to each statement using the Strength of Recommendation Taxonomy (SORT) criteria.

Results: The two literature searches produced 98 and 76 articles, respectively, that met search criteria. After screening the articles for relevance to the discussion topic, 19 articles were distributed to the panelists for review prior to the roundtable discussion. The panel unanimously voted to adopt 10 consensus statements and recommendations, 4 of which were given a strength of “A”, 1 of which was given a strength of “B”, and 5 of which were given a strength of “C”.

Conclusion: Psoriasis is a systemic disease with cutaneous manifestations and should be considered as such for adequate treatment. The 10 consensus statements created by the experts provide clinical recommendations on the systemic effects of psoriasis and important treatment considerations that can help guide clinicians on how to appropriately treat psoriasis of all severities. Furthermore, an emphasis is placed on recognizing treatment goals and making the next appropriate clinical decision for patients with mild to moderate disease who fail topical therapy.


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