Joint AAD–NPF Guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures

Psoriasis is a chronic, inflammatory, multisystem disease that affects up to 3.2% of the United States population. This guideline addresses important clinical questions arise in psoriasis management and care provides recommendations based on available evidence. The treatment with topical agents alternative medicine will be reviewed, emphasizing role dermatologists monitoring educating patients regarding benefits as well risks may associated. also address severity assessment methods adults. DisclaimerAdherence these guidelines not ensure successful every situation. Furthermore, should interpreted setting standard care, nor they deemed either inclusive all proper or exclusive other reasonably directed toward obtaining same results. ultimate judgment propriety any specific therapy must made by physician patient light circumstances presented individual known variability biological behavior disease. dosages used trials effective certain cases, some require shorter intervals between doses and/or higher particular methodology. reflects best data at time was prepared. results future studies revisions this reflect new data.Conflict interest statementThe American Academy Dermatology (AAD) strives produce evidence supplemented expert clinicians. Significant efforts are taken minimize potential for conflicts influence content. conflict complies Council Medical Specialty Societies Code Interactions Companies. Funding production medical pharmaceutical entities prohibited, full disclosure obtained evaluated contributors throughout development process, recusal manage identified relationships. AAD policy summary viewed www.aad.org.The information below represents authors who disclosed relationship industry during development. Authors (listed alphabetically) relevant respect noted an asterisk (?). In accordance policy, fewer than 51% workgroup members had interest.Participation one more below-listed activities constitutes conflict:•service member speaker bureau, consultant, advisory board, companies state drugs (US) Food Drug Administration (FDA) approved;•sponsored research funding investigator-initiated partial/full from FDA approved.Draft were developed through collaborative approach conflicted nonconflicted section leaders. Initial finalization.ScopeThis cover use (AM) adults severity; pediatric population covered separate section, “Joint Dermatology-National Foundation (NPF) patients.”1Menter A. Cordoro K.M. Davis D.M.R. et al.Joint [published correction appears J Am Acad Dermatol. 2020;82(3):574].J 2020; 82: 161-201Abstract Full Text PDF PubMed Scopus (0) Google ScholarMethodFor description methodology herein, please refer Appendix section.Definition reviewSee definition statement.IntroductionPsoriasis common inflammatory disease, affecting approximately population.2Rachakonda T.D. Schupp C.W. Armstrong A.W. prevalence among States.J 2014; 70: 512-516Abstract (415) Scholar While skin involvement most prominent manifestation recognition disorder imperative optimize reduce comorbidities.Topical medications treat mild moderate psoriasis. They frequently adjunctive therapies phototherapy, systemic, biologic therapy. Alternative typically part conventional care. It have origins outside usual Western practice desired benefit subset patients.3National Center Complementary Integrative HealthComplementary, Alternative, Health: What's Name? NCCIH Clearinghouse.https://nccih.nih.gov/health/integrative-healthDate: 2019Date accessed: October 1, 2019Google Scholar,4van de Kerkhof P.C. Cambazard F. Hutchinson P.E. al.The effect addition calcipotriol ointment (50 micrograms/g) acitretin psoriasis.Br 1998; 138: 84-89Crossref ScholarThis review AM modalities adult (Table I).Table IClinical questions1.What efficacy, effectiveness, adverse events following monotherapy combination adults?a.Topical corticosteroidsb.Calcineurin inhibitors (Topical tacrolimus pimecrolimus)c.Vitamin D analoguesd.Tazarotenee.Moisturizersf.Salicylic acidg.Anthralinh.Coal tari.Biologic agent combinationj.Nonbiologic combinationi.Methotrexateii.Cyclosporineiii.Acitretin2.What medicines psoriasis?a.Traditional Chinese medicineb.Herbal therapiesi.Aloe veraii.St John's wortc.Diet/dietary supplementsi.Fish oilii.Vitamin Diii.Curcumin (Turmeric)iv.Zincv.Gluten-free dietd.Mind/bodyi.Hypnosisii.Stress reduction/meditation3.What accuracy, utility, parameters using measures measure response treatment?a.Body surface area (BSA)b.Psoriasis Area Severity Index (PASI)c.Physician Global Assessment (PGA)d.PGA × BSAe.Psoriasis Symptom Inventory (PSI)f.Dermatology Life Quality (DLQI)g.Pruritus Open table tab I. Topical agentsTopical corticosteroidsEfficacyTopical corticosteroids, which provide high efficacy good safety, play key psoriasis, especially localized corticosteroids anti-inflammatory, antiproliferative, immunosuppressive, vasoconstrictive effects. These effects exerted via intracellular corticosteroid receptors, regulate gene transcription, including several code proinflammatory mediators. classified into 7 categories their activity, ranging strength ultra-high (class 1) low 6 7; Table II).5Cornell R.C. Stoughton R.B. Correlation vasoconstriction assay activity psoriasis.Arch 1985; 121: 63-67Crossref (157) Scholar, 6Bolognia J. Schaffer J.V. Cerroni L. Dermatology.4th ed. Elsevier, Philadelphia2018Google 7Gabros S. Zito P.M. corticosteroids.StatPearls. Treasure Island (FL), 8Jacob S.E. Steele T. Corticosteroid classes: quick reference guide patch test substances cross-reactivity.J 2006; 54: 723-727Abstract (61) ScholarTable IIClassification corticosteroid6Bolognia Scholar?Reprinted Dermatology: 2-Volume Set, 4th Edition, Jean Bolognia, Julie Schafer, Lorenzo Cerroni, Glucocorticosteroids, Page No. 2190, Copyright 2018, permission Elsevier.WHO potency groupClassificationTopical corticosteroidSuper-potentUltrahighClass 11.Augmented betamethasone dipropionate 0.05%aOintment.,bGel.2.Clobetasol propionate 0.05%aOintment.,bGel.,cCream.,dLotion.,eFoam.,fSolution.,gScalp solution application, classifications class 2.,hSpray.,iShampoo 0.05%.3.Desoximetasone 0.25%hSpray.4.Augmented diflorasone diacetate 0.05%aOintment.5.Fluocinonide 0.1%cCream.6.Flurandrenolide 4 ?g/cm2jTape.7.Halobetasol 0.05%aOintment.,cCream.HighClass 21.Amcinonide 0.1%aOintment.2.Betamethasone 0.05%aOintment.3.Augmented 0.05%cCream.,dLotion.4.Desoximetasone 0.25%aOintment.,cCream.5.Desoximetasone 0.05%bGel.6.Augmented 0.05%cCream.7.Diflorasone 0.05%aOintment.8.Fluocinonide 0.05%aOintment.,bGel.,cCream.,fSolution.9.Halcinonide 0.1%aOintment.,cCream.10.Mometasone furoate 0.1%aOintment.11.Triamcinolone acetonide 0.5%aOintment.Class 31.Amcinonide 0.1%cCream.,dLotion.2.Betamethasone 0.05%cCream.,kLotion, depending upon classification, 3 5.3.Betamethasone valerate 0.1%aOintment.4.Betamethasone 0.12%lFoam, 4.5.Diflorasone 0.05%cCream.6.Fluticasone 0.005%aOintment.7.Triamcinolone 0.1%aOintment.8.Triamcinolone 0.5%cCream.Moderate (medium)Class 41.Betamethasone 4.2.Desoximetasone 0.05%cCream.3.Fluocinolone 0.025%aOintment.4.Flurandrenolide 0.05%aOintment.5.Hydrocortisone 0.2%aOintment.6.Mometasone 0.1%cCream.,dLotion.7.Triamcinolone 0.1%cCream.,mKenalog (manufactured APOTHECON, Bristol-Myers Squibb Company; Princeton, NJ).8.Triamcinolone 0.2%hSpray.Class 51.Betamethasone 0.05%kLotion, 5.2.Betamethasone 0.1%cCream.,dLotion.3.Clocortolone pivalate 0.1%cCream.4.Fluocinolone 0.025%cCream.5.Fluocinolone 0.01%nOil.,oShampoo.6.Fluticasone 0.05%cCream.,dLotion.7.Flurandrenolide 0.05%cCream.,dLotion.8.Hydrocortisone butyrate 0.1%aOintment.,cCream.,dLotion.,fSolution.9.Hydrocortisone probutate 0.1%cCream.10.Hydrocortisone 0.2%cCream.11.Prednicarbate 0.1%aOintment.,cCream.12.Triamcinolone 0.025%aOintment.13.Triamcinolone 0.01%dLotion.LowClass 61.Alclometasone 0.05%aOintment.,cCream.2.Betamethasone 0.05%dLotion.3.Desonide 0.05%aOintment.,bGel.,cCream.,dLotion.,eFoam.4.Fluocinolone 0.01%cCream.,fSolution.5.Triamcinolone 0.025%cCream.,dLotion.Class 71.Dexamethasone sodium phosphate 0.1%cCream.2.Hydrocortisone 0.5%-2.5%aOintment.,bGel.,cCream.,dLotion.,fSolution.3.Methylprednisolone acetate 0.25%cCream.WHO, World Health Organization.? Reprinted Elsevier.a Ointment.b Gel.c Cream.d Lotion.e Foam.f Solution.g Scalp 2.h Spray.i Shampoo 0.05%.j Tape.k Lotion, 5.l Foam, 4.m Kenalog NJ).n Oil.o Shampoo. Choosing appropriate plus vehicle severity, location, preference, age patient. Lower face, intertriginous areas, areas susceptible steroid atrophy (eg, forearms) adults, classes 2 5 (moderate potency; II) generally recommended initial Areas thick, chronic plaques often 1 (ultrahigh-potency) corticosteroids. numerous randomized controlled (RCTs), different safe weeks severe plaque psoriasis.9Bernhard Whitmore C. Guzzo al.Evaluation halobetasol psoriasis: report two double-blind, vehicle-controlled studies.J 1991; 25: 1170-1174Abstract (30) 10Gottlieb A.B. Ford R.O. Spellman M.C. tolerability clobetasol foam 0.05% plaque-type nonscalp regions.J Cutan Med Surg. 2003; 7: 185-192Crossref 11Lebwohl M. Sherer D. Washenik K. al.A randomized, placebo-controlled study psoriasis.Int 2002; 41: 269-274Crossref (48) Evidence RCTs varies due differences designs, populations, end points, making it difficult do accurate statistical comparison majority published studies.For ultrahigh-potency rates vary 58% 92%.9Bernhard Scholar,10Gottlieb Scholar,12Camarasa J.M. Ortonne J.P. Dubertret Calcitriol shows greater persistence therapy.J Dermatolog Treat. 14: 8-13Crossref (41) Scholar,13Keegan B.R. Desoximetasone 0.25% spray relief scaling psoriasis.J Drugs 2015; 835-840PubMed trial 204 after treatment, group improved Physician's (PGA) scores 92% compared 39% vehicle-treated (P < .0003).9Bernhard An RCT 279 found 1), 68% achieved Static (PSGA) score 0 21% treated .0001).10Gottlieb Another double-blind 81 Investigator scale assess demonstrated marked improvement, almost completely clear 15% .0005).11Lebwohl ScholarFor high-potency 3) 74%. double blind-RCT 35 desoximetasone cream 2) weeks, 23% improvement mean overall evaluation .001).14Savin Desoximetasone—a corticosteroid: short-and long-term experiences.Cutis. 1978; 21: 403-407PubMed Two fluticasone 0.005%, corticosteroid, showed 69% achieved, good, excellent, 29% 30% = .00001).15Olsen E.A. Efficacy safety 0.005% psoriasis.Cutis. 1996; 57: 57-61PubMed moderate-potency 5) 70% 83%.16Pauporte Maibach H. Lowe N. al.Fluocinolone oil scalp 2004; 15: 360-364Crossref (33) Scholar,17Stein L.F. Sherr Solodkina G. Gottlieb Chaudhari U. Betamethasone 2001; 5: 303-307Crossref 40 revealed 0.12% 4) 50% 24% placebo 12 .001).17Stein fluocinolone 0.01% corticosteroid) proportion achieving better baseline (83% vs 36%; P .001).16Pauporte Additionally, superior hydrocortisone 0.1% 7) clearance, (79% 68%; .05).18James A multicenter comparing cream, 0.05%, hydrocortisone-17-butyrate 0.1%, applied twice daily 67: 2-9PubMed ScholarOwing inconsistent criteria design, comparisons complex. Nevertheless, systematic potent super-potent efficacious moderately corticosteroids.19Mason Mason A.R. Cork M.J. preparations review.Br 146: 351-364Crossref (141) ScholarTreatment such groin, hair-bearing skin, scalp, can challenging difficulty applying product selection. Therefore, selection hair density hairstyles preferences essential treatment. 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Company, NJ2018https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/012041s045lbl.pdfDate April 23, 2020Google injection volume pending lesional size affected.Risks/harms benefitsThe local include atrophy, striae, folliculitis, telangiectasia, purpura.25Abraham Roga steroid-damaged skin.Indian 59: 456-459Crossref (31) Face chronically forearms, greatest risk develop exacerbate acne, rosacea, perioral dermatitis, tinea infections occasionally cause contact dermatitis. Rebound (ie, when recurs before treatment) occur abrupt withdrawal although frequency phenomenon unknown. ultrahigh- 1-3) minimal atrophy.26Castela E. Archier Devaux al.Topical adrenal axis suppression atrophy.J Eur Venereol. 2012; 26: 47-51Crossref ScholarRisk hypothalamic pituitary extensive has been reported low.26Castela 13 studies, performed percentage reduction morning cortisol level 0% fluocinonide, 48% propionate, 18% dipropionate. adrenocorticotropic hormone stimulation tests, gold assessing hypothalamic-pituitary-adrenal suppression, always within normal ranges, even assessed months use.26Castela Rare systemic Cushing syndrome osteonecrosis femoral head.27Takahashi Tsuji Honma Ishida-Yamamoto Iizuka Femoral head patient.J 39: 887-888Crossref Scholar,28el Maghraoui Tabache Bezza Ghafir Ohayon V. Archane M.I. therapy.Clin Exp Rheumatol. 19: 233PubMed products contain nail because there isolated bone persistent use.29Malec-Milewska Sekowska Koleda Horosz B. 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Clinicians consider limiting no possible.34Clobex® Galderma Laboratories, L.P., Fort Worth, TX2012https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021535Orig1s003,%20021644Orig1s003lbl.pdfDate 17, event flare, repeated courses administered. Longer durations palms soles acceptable close attention Gradual recommended, but exact details tapering established. tapered off reducing day, then eventually times week, finally discontinuation if stable whole process. T