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Pathophysiology, Clinical Presentation, and Treatment of PsoriasisA Review

Educational Objective
To review the clinical management of patients with plaque psoriasis.
1 Credit CME
Abstract

Importance  Approximately 125 million people worldwide have psoriasis. Patients with psoriasis experience substantial morbidity and increased rates of inflammatory arthritis, cardiometabolic diseases, and mental health disorders.

Observations  Plaque psoriasis is the most common variant of psoriasis. The most rapid advancements addressing plaque psoriasis have been in its pathogenesis, genetics, comorbidities, and biologic treatments. Plaque psoriasis is associated with a number of comorbidities including psoriatic arthritis, cardiometabolic diseases, and depression. For patients with mild psoriasis, topical agents remain the mainstay of treatment, and they include topical corticosteroids, vitamin D analogues, calcineurin inhibitors, and keratolytics. The American Academy of Dermatology-National Psoriasis Foundation guidelines recommend biologics as an option for first-line treatment of moderate to severe plaque psoriasis because of their efficacy in treating it and acceptable safety profiles. Specifically, inhibitors to tumor necrosis factor α (TNF-α) include etanercept, adalimumab, certolizumab, and infliximab. Other biologics inhibit cytokines such as the p40 subunit of the cytokines IL-12 and IL-13 (ustekinumab), IL-17 (secukinumab, ixekizumab, bimekizumab, and brodalumab), and the p19 subunit of IL-23 (guselkumab, tildrakizumab, risankizumab, and mirikizumab). Biologics that inhibit TNF-α, p40IL-12/23, and IL-17 are also approved for the treatment of psoriatic arthritis. Oral treatments include traditional agents such as methotrexate, acitretin, cyclosporine, and the advanced small molecule apremilast, which is a phosphodiesterase 4 inhibitor. The most commonly prescribed light therapy used to treat plaque psoriasis is narrowband UV-B phototherapy.

Conclusions and Relevance  Psoriasis is an inflammatory skin disease that is associated with multiple comorbidities and substantially diminishes patients’ quality of life. Topical therapies remain the cornerstone for treating mild psoriasis. Therapeutic advancements for moderate to severe plaque psoriasis include biologics that inhibit TNF-α, p40IL-12/23, IL-17, and p19IL-23, as well as an oral phosphodiesterase 4 inhibitor.

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Article Information

Corresponding Author: April W. Armstrong, MD, MPH, University of Southern California, 1975 Zonal Ave, KAM 510, MC 9034, Los Angeles, CA 90089 (aprilarmstrong@post.harvard.edu).

Accepted for Publication: March 10, 2020.

Conflict of Interest Disclosures: Dr Armstrong reports receipt of grants and personal fees from AbbVie, Bristol-Myers Squibb, Dermavant, Eli Lilly, Janssen, Leo Pharma, Novartis, Regeneron, and UCB; personal fees from Boehringer Ingelheim, Genentech, Merck, Modernizing Medicine, Ortho Dermatologics, Pfizer, Sanofi Genzyme, and Celgene; and grants from Dermira and Kyowa Hakko Kirin outside the submitted work. Dr Read reports receipt of grants from the National Psoriasis Foundation outside the submitted work.

References
1.
Michalek  IM , Loring  B , John  SM .  A systematic review of worldwide epidemiology of psoriasis.   J Eur Acad Dermatol Venereol. 2017;31(2):205-212. doi:10.1111/jdv.13854PubMedGoogle Scholar
2.
World Health Organization.  Global Report on Psoriasis: World Health Organization, 2016. Accessed February 13, 2020. https://apps.who.int/iris/handle/10665/204417
3.
Rachakonda  TD , Schupp  CW , Armstrong  AW .  Psoriasis prevalence among adults in the United States.   J Am Acad Dermatol. 2014;70(3):512-516. doi:10.1016/j.jaad.2013.11.013PubMedGoogle Scholar
4.
Paller  AS , Singh  R , Cloutier  M ,  et al.  Prevalence of psoriasis in children and adolescents in the United States: a claims-based analysis.   J Drugs Dermatol. 2018;17(2):187-194.PubMedGoogle Scholar
5.
Menter  A , Korman  NJ , Elmets  CA ,  et al; American Academy of Dermatology.  Guidelines of care for the management of psoriasis and psoriatic arthritis: section 3, guidelines of care for the management and treatment of psoriasis with topical therapies.   J Am Acad Dermatol. 2009;60(4):643-659. doi:10.1016/j.jaad.2008.12.032PubMedGoogle Scholar
6.
Menter  A , Korman  NJ , Elmets  CA ,  et al.  Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4, guidelines of care for the management and treatment of psoriasis with traditional systemic agents.   J Am Acad Dermatol. 2009;61(3):451-485. doi:10.1016/j.jaad.2009.03.027PubMedGoogle Scholar
7.
Menter  A , Strober  BE , Kaplan  DH ,  et al.  Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics.   J Am Acad Dermatol. 2019;80(4):1029-1072. doi:10.1016/j.jaad.2018.11.057PubMedGoogle Scholar
8.
Elmets  CA , Leonardi  CL , Davis  DMR ,  et al.  Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities.   J Am Acad Dermatol. 2019;80(4):1073-1113. doi:10.1016/j.jaad.2018.11.058PubMedGoogle Scholar
9.
Elmets  CA , Lim  HW , Stoff  B ,  et al.  Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis with phototherapy.   J Am Acad Dermatol. 2019;81(3):775-804. doi:10.1016/j.jaad.2019.04.042PubMedGoogle Scholar
10.
Nestle  FO , Kaplan  DH , Barker  J .  Mechanisms of disease: psoriasis.   N Engl J Med. 2009;361(5):496-509. doi:10.1109/APCCAS.2002.1114931PubMedGoogle Scholar
11.
Alwan  W , Nestle  FO .  Pathogenesis and treatment of psoriasis: exploiting pathophysiological pathways for precision medicine.   Clin Exp Rheumatol. 2015;33(5)(suppl 93):S2-S6.PubMedGoogle Scholar
12.
Parisi  R , Symmons  DPM , Griffiths  CEM , Ashcroft  DM ; Identification and Management of Psoriasis and Associated ComorbidiTy (IMPACT) project team.  Global epidemiology of psoriasis: a systematic review of incidence and prevalence.   J Invest Dermatol. 2013;133(2):377-385. doi:10.1038/jid.2012.339PubMedGoogle Scholar
13.
Tsai  TF , Wang  TS , Hung  ST ,  et al.  Epidemiology and comorbidities of psoriasis patients in a national database in Taiwan.   J Dermatol Sci. 2011;63(1):40-46. doi:10.1016/j.jdermsci.2011.03.002PubMedGoogle Scholar
14.
Nair  RP , Stuart  PE , Nistor  I ,  et al.  Sequence and haplotype analysis supports HLA-C as the psoriasis susceptibility 1 gene.   Am J Hum Genet. 2006;78(5):827-851. doi:10.1086/503821PubMedGoogle Scholar
15.
Tsoi  LC , Stuart  PE , Tian  C ,  et al.  Large scale meta-analysis characterizes genetic architecture for common psoriasis associated variants.   Nat Commun. 2017;8:15382. doi:10.1038/ncomms15382PubMedGoogle Scholar
16.
Liu  Y , Helms  C , Liao  W ,  et al.  A genome-wide association study of psoriasis and psoriatic arthritis identifies new disease loci.   PLoS Genet. 2008;4(3):e1000041. doi:10.1371/journal.pgen.1000041PubMedGoogle Scholar
17.
Andressen  C , Henseler  T .  Inheritance of psoriasis: analysis of 2035 family histories [article in German].   Hautarzt. 1982;33(4):214-217. PubMedGoogle Scholar
18.
Armstrong  AW .  Psoriasis provoked or exacerbated by medications: identifying culprit drugs.   JAMA Dermatol. 2014;150(9):963. doi:10.1001/jamadermatol.2014.1019PubMedGoogle Scholar
19.
Yeung  H , Takeshita  J , Mehta  NN ,  et al.  Psoriasis severity and the prevalence of major medical comorbidity: a population-based study.   JAMA Dermatol. 2013;149(10):1173-1179. doi:10.1001/jamadermatol.2013.5015PubMedGoogle Scholar
20.
Mease  P , Goffe  BS .  Diagnosis and treatment of psoriatic arthritis.   J Am Acad Dermatol. 2005;52(1):1-19. doi:10.1016/j.jaad.2004.06.013PubMedGoogle Scholar
21.
Tom  BDM , Chandran  V , Farewell  VT , Rosen  CF , Gladman  DD .  Validation of the Toronto psoriatic arthritis screen version 2 (ToPAS 2).   J Rheumatol. 2015;42(5):841-846. doi:10.3899/jrheum.140857PubMedGoogle Scholar
22.
Husni  ME , Meyer  KH , Cohen  DS , Mody  E , Qureshi  AA .  The PASE questionnaire: pilot-testing a psoriatic arthritis screening and evaluation tool.   J Am Acad Dermatol. 2007;57(4):581-587. doi:10.1016/j.jaad.2007.04.001PubMedGoogle Scholar
23.
Coates  LC , Aslam  T , Al Balushi  F ,  et al.  Comparison of three screening tools to detect psoriatic arthritis in patients with psoriasis (CONTEST study).   Br J Dermatol. 2013;168(4):802-807. doi:10.1111/bjd.12190PubMedGoogle Scholar
24.
Tillett  W , Costa  L , Jadon  D ,  et al.  The ClASsification for Psoriatic ARthritis (CASPAR) criteria—a retrospective feasibility, sensitivity, and specificity study.   J Rheumatol. 2012;39(1):154-156. doi:10.3899/jrheum.110845PubMedGoogle Scholar
25.
Mody  E , Husni  ME , Schur  P , Qureshi  AA .  Multidisciplinary evaluation of patients with psoriasis presenting with musculoskeletal pain: a dermatology: rheumatology clinic experience.   Br J Dermatol. 2007;157(5):1050-1051. doi:10.1111/j.1365-2133.2007.08139.xPubMedGoogle Scholar
26.
Mansouri  B , Kivelevitch  D , Natarajan  B ,  et al.  Comparison of coronary artery calcium scores between patients with psoriasis and type 2 diabetes.   JAMA Dermatol. 2016;152(11):1244-1253. doi:10.1001/jamadermatol.2016.2907PubMedGoogle Scholar
27.
Lerman  JB , Joshi  AA , Chaturvedi  A ,  et al.  Coronary plaque characterization in psoriasis reveals high-risk features that improve after treatment in a prospective observational study.   Circulation. 2017;136(3):263-276. doi:10.1161/CIRCULATIONAHA.116.026859PubMedGoogle Scholar
28.
Armstrong  AW , Harskamp  CT , Ledo  L , Rogers  JH , Armstrong  EJ .  Coronary artery disease in patients with psoriasis referred for coronary angiography.   Am J Cardiol. 2012;109(7):976-980. doi:10.1016/j.amjcard.2011.11.025PubMedGoogle Scholar
29.
Dey  AK , Joshi  AA , Chaturvedi  A ,  et al.  Association between skin and aortic vascular inflammation in patients with psoriasis: a case-cohort study using positron emission tomography/computed tomography.   JAMA Cardiol. 2017;2(9):1013-1018. doi:10.1001/jamacardio.2017.1213PubMedGoogle Scholar
30.
Armstrong  AW , Guérin  A , Sundaram  M ,  et al.  Psoriasis and risk of diabetes-associated microvascular and macrovascular complications.   J Am Acad Dermatol. 2015;72(6):968-77.e2. doi:10.1016/j.jaad.2015.02.1095PubMedGoogle Scholar
31.
Armstrong  AW , Harskamp  CT , Armstrong  EJ .  Psoriasis and metabolic syndrome: a systematic review and meta-analysis of observational studies.   J Am Acad Dermatol. 2013;68(4):654-662. doi:10.1016/j.jaad.2012.08.015PubMedGoogle Scholar
32.
Armstrong  AW , Harskamp  CT , Armstrong  EJ .  Psoriasis and the risk of diabetes mellitus: a systematic review and meta-analysis.   JAMA Dermatol. 2013;149(1):84-91. doi:10.1001/2013.jamadermatol.406PubMedGoogle Scholar
33.
Gelfand  JM , Neimann  AL , Shin  DB , Wang  X , Margolis  DJ , Troxel  AB .  Risk of myocardial infarction in patients with psoriasis.   JAMA. 2006;296(14):1735-1741. doi:10.1001/jama.296.14.1735PubMedGoogle Scholar
34.
Ahlehoff  O , Gislason  GH , Charlot  M ,  et al.  Psoriasis is associated with clinically significant cardiovascular risk: a Danish nationwide cohort study.   J Intern Med. 2011;270(2):147-157. doi:10.1111/j.1365-2796.2010.02310.xPubMedGoogle Scholar
35.
Lin  HW , Wang  KH , Lin  HC , Lin  HC .  Increased risk of acute myocardial infarction in patients with psoriasis: a 5-year population-based study in Taiwan.   J Am Acad Dermatol. 2011;64(3):495-501. doi:10.1016/j.jaad.2010.01.050PubMedGoogle Scholar
36.
Gelfand  JM , Dommasch  ED , Shin  DB ,  et al.  The risk of stroke in patients with psoriasis.   J Invest Dermatol. 2009;129(10):2411-2418. doi:10.1038/jid.2009.112PubMedGoogle Scholar
37.
Ahlehoff  O , Gislason  GH , Jørgensen  CH ,  et al.  Psoriasis and risk of atrial fibrillation and ischaemic stroke: a Danish nationwide cohort study.   Eur Heart J. 2012;33(16):2054-2064. doi:10.1093/eurheartj/ehr285PubMedGoogle Scholar
38.
Abuabara  K , Azfar  RS , Shin  DB , Neimann  AL , Troxel  AB , Gelfand  JM .  Cause-specific mortality in patients with severe psoriasis: a population-based cohort study in the UK.   Br J Dermatol. 2010;163(3):586-592. doi:10.1111/j.1365-2133.2010.09941.xPubMedGoogle Scholar
39.
Stern  RS , Huibregtse  A .  Very severe psoriasis is associated with increased noncardiovascular mortality but not with increased cardiovascular risk.   J Invest Dermatol. 2011;131(5):1159-1166. doi:10.1038/jid.2010.399PubMedGoogle Scholar
40.
Armstrong  EJ , Harskamp  CT , Armstrong  AW .  Psoriasis and major adverse cardiovascular events: a systematic review and meta-analysis of observational studies.   J Am Heart Assoc. 2013;2(2):e000062. doi:10.1161/JAHA.113.000062PubMedGoogle Scholar
41.
Mehta  NN , Azfar  RS , Shin  DB , Neimann  AL , Troxel  AB , Gelfand  JM .  Patients with severe psoriasis are at increased risk of cardiovascular mortality: cohort study using the General Practice Research Database.   Eur Heart J. 2010;31(8):1000-1006. doi:10.1093/eurheartj/ehp567PubMedGoogle Scholar
42.
Singh  S , Taylor  C , Kornmehl  H , Armstrong  AW .  Psoriasis and suicidality: a systematic review and meta-analysis.   J Am Acad Dermatol. 2017;77(3):425-440.e2. doi:10.1016/j.jaad.2017.05.019PubMedGoogle Scholar
43.
Dowlatshahi  EA , Wakkee  M , Arends  LR , Nijsten  T .  The prevalence and odds of depressive symptoms and clinical depression in psoriasis patients: a systematic review and meta-analysis.   J Invest Dermatol. 2014;134(6):1542-1551. doi:10.1038/jid.2013.508PubMedGoogle Scholar
44.
Dalgard  FJ , Gieler  U , Tomas-Aragones  L ,  et al.  The psychological burden of skin diseases: a cross-sectional multicenter study among dermatological out-patients in 13 European countries.   J Invest Dermatol. 2015;135(4):984-991. doi:10.1038/jid.2014.530PubMedGoogle Scholar
45.
Eppinga  H , Poortinga  S , Thio  HB ,  et al.  Prevalence and phenotype of concurrent psoriasis and inflammatory bowel disease.   Inflamm Bowel Dis. 2017;23(10):1783-1789. doi:10.1097/MIB.0000000000001169PubMedGoogle Scholar
46.
Karason  A , Gudjonsson  JE , Upmanyu  R ,  et al.  A susceptibility gene for psoriatic arthritis maps to chromosome 16q: evidence for imprinting.   Am J Hum Genet. 2003;72(1):125-131. doi:10.1086/345646PubMedGoogle Scholar
47.
Singh  JA , Guyatt  G , Ogdie  A ,  et al.  Special article: 2018 American College of Rheumatology/National Psoriasis Foundation guideline for the treatment of psoriatic arthritis.   Arthritis Rheumatol. 2019;71(1):5-32. doi:10.1002/art.40726PubMedGoogle Scholar
48.
Lebwohl  M , Menter  A , Weiss  J ,  et al.  Calcitriol 3 microg/g ointment in the management of mild to moderate plaque type psoriasis: results from 2 placebo-controlled, multicenter, randomized double-blind, clinical studies.   J Drugs Dermatol. 2007;6(4):428-435.PubMedGoogle Scholar
49.
Soleymani  T , Hung  T , Soung  J .  The role of vitamin D in psoriasis: a review.   Int J Dermatol. 2015;54(4):383-392. doi:10.1111/ijd.12790PubMedGoogle Scholar
50.
Oranje  AP , Marcoux  D , Svensson  A ,  et al.  Topical calcipotriol in childhood psoriasis.   J Am Acad Dermatol. 1997;36(2 Pt 1):203-208. doi:10.1016/S0190-9622(97)70281-0PubMedGoogle Scholar
51.
Darley  CR , Cunliffe  WJ , Green  CM , Hutchinson  PE , Klaber  MR , Downes  N .  Safety and efficacy of calcipotriol ointment (Dovonex) in treating children with psoriasis vulgaris.   Br J Dermatol. 1996;135(3):390-393. doi:10.1111/j.1365-2133.1996.tb01501.xPubMedGoogle Scholar
52.
Gribetz  C , Ling  M , Lebwohl  M ,  et al.  Pimecrolimus cream 1% in the treatment of intertriginous psoriasis: a double-blind, randomized study.   J Am Acad Dermatol. 2004;51(5):731-738. doi:10.1016/j.jaad.2004.06.010PubMedGoogle Scholar
53.
Liao  YH , Chiu  HC , Tseng  YS , Tsai  TF .  Comparison of cutaneous tolerance and efficacy of calcitriol 3 microg g(-1) ointment and tacrolimus 0.3 mg g(-1) ointment in chronic plaque psoriasis involving facial or genitofemoral areas: a double-blind, randomized controlled trial.   Br J Dermatol. 2007;157(5):1005-1012. doi:10.1111/j.1365-2133.2007.08201.xPubMedGoogle Scholar
54.
Weinstein  GD , Krueger  GG , Lowe  NJ ,  et al.  Tazarotene gel, a new retinoid, for topical therapy of psoriasis: vehicle-controlled study of safety, efficacy, and duration of therapeutic effect.   J Am Acad Dermatol. 1997;37(1):85-92. doi:10.1016/S0190-9622(97)70216-0PubMedGoogle Scholar
55.
Koo  JY , Lowe  NJ , Lew-Kaya  DA ,  et al.  Tazarotene plus UVB phototherapy in the treatment of psoriasis.   J Am Acad Dermatol. 2000;43(5 Pt 1):821-828. doi:10.1067/mjd.2000.107940PubMedGoogle Scholar
56.
Leonardi  C , Bagel  J , Yamauchi  P ,  et al.  Efficacy and safety of calcipotriene plus betamethasone dipropionate aerosol foam in patients with psoriasis vulgaris—a randomized phase III study (PSO-FAST).   J Drugs Dermatol. 2015;14(12):1468-1477.PubMedGoogle Scholar
57.
Bruner  CR , Feldman  SR , Ventrapragada  M , Fleischer  AB  Jr .  A systematic review of adverse effects associated with topical treatments for psoriasis.   Dermatol Online J. 2003;9(1):2.PubMedGoogle Scholar
58.
Gold  LS , Lebwohl  MG , Sugarman  JL ,  et al.  Safety and efficacy of a fixed combination of halobetasol and tazarotene in the treatment of moderate-to-severe plaque psoriasis: results of 2 phase 3 randomized controlled trials.   J Am Acad Dermatol. 2018;79(2):287-293. doi:10.1016/j.jaad.2018.03.040PubMedGoogle Scholar
59.
Lebwohl  MG , Sugarman  JL , Gold  LS ,  et al.  Long-term safety results from a phase 3 open-label study of a fixed combination halobetasol propionate 0.01% and tazarotene 0.045% lotion in moderate-to-severe plaque psoriasis.   J Am Acad Dermatol. 2019;80(1):282-285. doi:10.1016/j.jaad.2018.09.002PubMedGoogle Scholar
60.
Griffiths  CEM , Reich  K , Lebwohl  M ,  et al; UNCOVER-2 and UNCOVER-3 Investigators.  Comparison of ixekizumab with etanercept or placebo in moderate-to-severe psoriasis (UNCOVER-2 and UNCOVER-3): results from two phase 3 randomised trials.   Lancet. 2015;386(9993):541-551. doi:10.1016/S0140-6736(15)60125-8PubMedGoogle Scholar
61.
Ito  K , Koga  M , Shibayama  Y , Tatematsu  S , Nakayama  J , Imafuku  S .  Proactive treatment with calcipotriol reduces recurrence of plaque psoriasis.   J Dermatol. 2016;43(4):402-405. doi:10.1111/1346-8138.13158PubMedGoogle Scholar
62.
Papp  KA , Tyring  S , Lahfa  M ,  et al; Etanercept Psoriasis Study Group.  A global phase III randomized controlled trial of etanercept in psoriasis: safety, efficacy, and effect of dose reduction.   Br J Dermatol. 2005;152(6):1304-1312. doi:10.1111/j.1365-2133.2005.06688.xPubMedGoogle Scholar
63.
Paller  AS , Siegfried  EC , Langley  RG ,  et al; Etanercept Pediatric Psoriasis Study Group.  Etanercept treatment for children and adolescents with plaque psoriasis.   N Engl J Med. 2008;358(3):241-251. doi:10.1056/NEJMoa066886PubMedGoogle Scholar
64.
Menter  A , Tyring  SK , Gordon  K ,  et al.  Adalimumab therapy for moderate to severe psoriasis: a randomized, controlled phase III trial.   J Am Acad Dermatol. 2008;58(1):106-115. doi:10.1016/j.jaad.2007.09.010PubMedGoogle Scholar
65.
Saurat  JH , Stingl  G , Dubertret  L ,  et al; CHAMPION Study Investigators.  Efficacy and safety results from the randomized controlled comparative study of adalimumab vs. methotrexate vs. placebo in patients with psoriasis (CHAMPION).   Br J Dermatol. 2008;158(3):558-566. doi:10.1111/j.1365-2133.2007.08315.xPubMedGoogle Scholar
66.
Gottlieb  AB , Blauvelt  A , Thaçi  D ,  et al.  Certolizumab pegol for the treatment of chronic plaque psoriasis: results through 48 weeks from 2 phase 3, multicenter, randomized, double-blinded, placebo-controlled studies (CIMPASI-1 and CIMPASI-2).   J Am Acad Dermatol. 2018;79(2):302-314.e6. doi:10.1016/j.jaad.2018.04.012PubMedGoogle Scholar
67.
Reich  K , Nestle  FO , Papp  K ,  et al; EXPRESS study investigators.  Infliximab induction and maintenance therapy for moderate-to-severe psoriasis: a phase III, multicentre, double-blind trial.   Lancet. 2005;366(9494):1367-1374. doi:10.1016/S0140-6736(05)67566-6PubMedGoogle Scholar
68.
Barker  J , Hoffmann  M , Wozel  G ,  et al.  Efficacy and safety of infliximab vs. methotrexate in patients with moderate-to-severe plaque psoriasis: results of an open-label, active-controlled, randomized trial (RESTORE1).   Br J Dermatol. 2011;165(5):1109-1117. doi:10.1111/j.1365-2133.2011.10615.xPubMedGoogle Scholar
69.
Langley  RG , Elewski  BE , Lebwohl  M ,  et al; ERASURE Study Group; FIXTURE Study Group.  Secukinumab in plaque psoriasis—results of two phase 3 trials.   N Engl J Med. 2014;371(4):326-338. doi:10.1056/NEJMoa1314258PubMedGoogle Scholar
70.
Blauvelt  A , Reich  K , Tsai  TF ,  et al.  Secukinumab is superior to ustekinumab in clearing skin of subjects with moderate-to-severe plaque psoriasis up to 1 year: results from the CLEAR study.   J Am Acad Dermatol. 2017;76(1):60-69.e9. doi:10.1016/j.jaad.2016.08.008PubMedGoogle Scholar
71.
Gottlieb  A , Sullivan  J , van Doorn  M ,  et al.  Secukinumab shows significant efficacy in palmoplantar psoriasis: results from GESTURE, a randomized controlled trial.   J Am Acad Dermatol. 2017;76(1):70-80. doi:10.1016/j.jaad.2016.07.058PubMedGoogle Scholar
72.
Reich  K , Sullivan  J , Arenberger  P ,  et al.  Effect of secukinumab on the clinical activity and disease burden of nail psoriasis: 32-week results from the randomized placebo-controlled TRANSFIGURE trial.   Br J Dermatol. 2019;181(5):954-966. doi:10.1111/bjd.17351PubMedGoogle Scholar
73.
Bagel  J , Duffin  KC , Moore  A ,  et al.  The effect of secukinumab on moderate-to-severe scalp psoriasis: Results of a 24-week, randomized, double-blind, placebo-controlled phase 3b study.   J Am Acad Dermatol. 2017;77(4):667-674. doi:10.1016/j.jaad.2017.05.033PubMedGoogle Scholar
74.
Mease  PJ , Smolen  JS , Behrens  F ,  et al  A head-to-head comparison of the efficacy and safety of ixekizumab and adalimumab in biological-naïve patients with active psoriatic arthritis: 24-week results of a randomised, open-label, blinded-assessor trial.   Ann Rheum Dis. 2019;79(1):123-131. doi:10.1136/annrheumdis-2019-215386.PubMedGoogle Scholar
75.
Paul  C , Griffiths  CEM , van de Kerkhof  PCM ,  et al.  Ixekizumab provides superior efficacy compared with ustekinumab over 52 weeks of treatment: results from IXORA-S, a phase 3 study.   J Am Acad Dermatol. 2019;80(1):70-79.e3. doi:10.1016/j.jaad.2018.06.039PubMedGoogle Scholar
76.
Lebwohl  M , Strober  B , Menter  A ,  et al.  Phase 3 studies comparing brodalumab with ustekinumab in psoriasis.   N Engl J Med. 2015;373(14):1318-1328. doi:10.1056/NEJMoa1503824PubMedGoogle Scholar
77.
Papp  KA , Langley  RG , Lebwohl  M ,  et al; PHOENIX 2 Study Investigators.  Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 52-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 2).   Lancet. 2008;371(9625):1675-1684. doi:10.1016/S0140-6736(08)60726-6PubMedGoogle Scholar
78.
Landells  I , Marano  C , Hsu  MC ,  et al.  Ustekinumab in adolescent patients age 12 to 17 years with moderate-to-severe plaque psoriasis: results of the randomized phase 3 CADMUS study.   J Am Acad Dermatol. 2015;73(4):594-603. doi:10.1016/j.jaad.2015.07.002PubMedGoogle Scholar
79.
Griffiths  CEM , Strober  BE , van de Kerkhof  P ,  et al; ACCEPT Study Group.  Comparison of ustekinumab and etanercept for moderate-to-severe psoriasis.   N Engl J Med. 2010;362(2):118-128. doi:10.1056/NEJMoa0810652PubMedGoogle Scholar
80.
Blauvelt  A , Papp  KA , Griffiths  CEM ,  et al.  Efficacy and safety of guselkumab, an anti-interleukin-23 monoclonal antibody, compared with adalimumab for the continuous treatment of patients with moderate to severe psoriasis: results from the phase III, double-blinded, placebo- and active comparator–controlled VOYAGE 1 trial.   J Am Acad Dermatol. 2017;76(3):405-417. doi:10.1016/j.jaad.2016.11.041PubMedGoogle Scholar
81.
Reich  K , Armstrong  AW , Langley  RG ,  et al.  Guselkumab versus secukinumab for the treatment of moderate-to-severe psoriasis (ECLIPSE): results from a phase 3, randomised controlled trial.   Lancet. 2019;394(10201):831-839. doi:10.1016/S0140-6736(19)31773-8PubMedGoogle Scholar
82.
Reich  K , Papp  KA , Blauvelt  A ,  et al.  Tildrakizumab versus placebo or etanercept for chronic plaque psoriasis (reSURFACE 1 and reSURFACE 2): results from two randomised controlled, phase 3 trials.   Lancet. 2017;390(10091):276-288. doi:10.1016/S0140-6736(17)31279-5PubMedGoogle Scholar
83.
Gordon  KB , Strober  B , Lebwohl  M ,  et al.  Efficacy and safety of risankizumab in moderate-to-severe plaque psoriasis (UltIMMa-1 and UltIMMa-2): results from two double-blind, randomised, placebo-controlled and ustekinumab-controlled phase 3 trials.   Lancet. 2018;392(10148):650-661. doi:10.1016/S0140-6736(18)31713-6PubMedGoogle Scholar
84.
Reich  K , Gooderham  M , Thaçi  D ,  et al.  Risankizumab compared with adalimumab in patients with moderate-to-severe plaque psoriasis (IMMvent): a randomised, double-blind, active-comparator-controlled phase 3 trial.   Lancet. 2019;394(10198):576-586. doi:10.1016/S0140-6736(19)30952-3PubMedGoogle Scholar
85.
Warren  RB , Mrowietz  U , von Kiedrowski  R ,  et al.  An intensified dosing schedule of subcutaneous methotrexate in patients with moderate to severe plaque-type psoriasis (METOP): a 52 week, multicentre, randomised, double-blind, placebo-controlled, phase 3 trial.   Lancet. 2017;389(10068):528-537. doi:10.1016/S0140-6736(16)32127-4PubMedGoogle Scholar
86.
Papp  K , Reich  K , Leonardi  CL ,  et al.  Apremilast, an oral phosphodiesterase 4 (PDE4) inhibitor, in patients with moderate to severe plaque psoriasis: results of a phase III, randomized, controlled trial (Efficacy and Safety Trial Evaluating the Effects of Apremilast in Psoriasis [ESTEEM] 1).   J Am Acad Dermatol. 2015;73(1):37-49. doi:10.1016/j.jaad.2015.03.049PubMedGoogle Scholar
87.
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(3):e305-e311. doi:10.1111/j.1468-3083.2012.04644.xPubMedGoogle Scholar
88.
Ellis  CN , Fradin  MS , Messana  JM ,  et al.  Cyclosporine for plaque-type psoriasis: results of a multidose, double-blind trial.   N Engl J Med. 1991;324(5):277-284. doi:10.1056/NEJM199101313240501PubMedGoogle Scholar
89.
Armstrong  AW , Puig  L , Joshi  A ,  et al.  Comparison of biologics and oral treatments for plaque psoriasis: a meta-analysis.   JAMA Dermatol. Published online February 5, 2020. doi:10.1001/jamadermatol.2019.4029PubMedGoogle Scholar
90.
Stern  RS ; PUVA Follow-Up Study.  The risk of squamous cell and basal cell cancer associated with psoralen and ultraviolet A therapy: a 30-year prospective study.   J Am Acad Dermatol. 2012;66(4):553-562. doi:10.1016/j.jaad.2011.04.004PubMedGoogle Scholar
91.
Kimball  AB , Rothman  KJ , Kricorian  G ,  et al.  OBSERVE-5: observational postmarketing safety surveillance registry of etanercept for the treatment of psoriasis final 5-year results.   J Am Acad Dermatol. 2015;72(1):115-122. doi:10.1016/j.jaad.2014.08.050PubMedGoogle Scholar
92.
Menter  A , Thaçi  D , Wu  JJ ,  et al.  Long-term safety and effectiveness of adalimumab for moderate to severe psoriasis: results from 7-year interim analysis of the ESPRIT registry.   Dermatol Ther (Heidelb). 2017;7(3):365-381. doi:10.1007/s13555-017-0198-xPubMedGoogle Scholar
93.
Kalb  RE , Fiorentino  DF , Lebwohl  MG ,  et al.  Risk of serious infection with biologic and systemic treatment of psoriasis: results from the psoriasis longitudinal assessment and registry (PSOLAR).   JAMA Dermatol. 2015;151(9):961-969. doi:10.1001/jamadermatol.2015.0718PubMedGoogle Scholar
94.
Mariette  X , Matucci-Cerinic  M , Pavelka  K ,  et al.  Malignancies associated with tumour necrosis factor inhibitors in registries and prospective observational studies: a systematic review and meta-analysis.   Ann Rheum Dis. 2011;70(11):1895-1904. doi:10.1136/ard.2010.149419PubMedGoogle Scholar
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