Newer agents for psoriasis in adults

• Published in: BMJ (Online) 2014-07, Vol.349 (jul09 1), p.g4026-g4026
• Main Authors: Jabbar-Lopez, Z K, Wu, K C P, Reynolds, N J
• Format: Article
• Language: English
• Subjects: Adult; Antibodies, Monoclonal - therapeutic use; Biological products; Calcitriol - analogs & derivatives; Calcitriol - therapeutic use; Confidence intervals; Dermatologic Agents - therapeutic use; Dihydroxycholecalciferols - therapeutic use; Drug dosages; Fumarates - therapeutic use; Humans; Immunotherapy; Licenses; Light therapy; Psoriasis; Psoriasis - drug therapy; Psoriasis - radiotherapy; Quality; Skin; THERAPEUTICS; Tumor necrosis factor-TNF; Ultraviolet Therapy; Vitamin D; Vitamins - therapeutic use
• ISSN: 0959-8138; 1756-1833; 1756-1833
• DOI: 10.1136/bmj.g4026

Indications for specialist referral 1 5 Diagnostic uncertainty Severe or extensive psoriasis-for example, psoriasis that affects more than 10% of the body surface area Psoriasis that cannot be controlled with topical drugs Acute guttate psoriasis that requires phototherapy Nail disease with a major functional or cosmetic impact Psoriasis that has a major impact on a person's physical, psychological, or social wellbeing Symptoms and signs suggestive of psoriatic arthritis Generalised pustular psoriasis or erythroderma (both urgent referrals) Vitamin D and its analogues: 8 A European guidelines' systematic review of 19 studies (RCTs and observational studies) found that 25-58% of patients with mild to moderate chronic plaque psoriasis treated with vitamin D or its analogues showed a "significant improvement" or "near clearance" after twice daily application for six to eight weeks. 9 Absolute efficacy, measured using investigator's assessment of clear or nearly clear, gives a number needed to treat (NNT) of 7 (4 to 18; three moderate quality RCTs) for once daily calcipotriol, 2 (2 to 3; four moderate quality RCTs) for twice daily calcipotriol, 3 (1 to 7; two moderate quality RCTs) for twice daily calcitriol, and 8 (3 to 56; one low quality RCT) for once daily tacalcitol. 1 The UK's National Institute for Health and Care Excellence (NICE) concluded that combination therapy with a vitamin D analogue and corticosteroid was more effective than either alone. 1 Thus UK guidelines suggest that vitamin D and its analogues should be used as first line topical treatment in combination with a potent topical corticosteroid (prescribed as separate applications).