Information for the public
If topical treatment does not control your psoriasis and your psoriasis has a considerable impact on your wellbeing, and is widespread or occurs at sites that cause you problems in daily functioning or high levels of distress you should be offered treatment called systemic treatment. There are 2 types of systemic therapy known as systemic non-biological therapy and systemic biological therapy.
You should also be offered systemic treatment if phototherapy does not control your psoriasis or cannot be used (for example, if you are at high risk of skin cancer or cannot receive phototherapy for practical reasons such as transport or getting time off work).
All systemic drugs have the potential to give rise to serious side effects and should only be prescribed in specialist care. Your specialist may formally ask other healthcare professionals to help supervise and monitor your treatment. You may be offered topical therapy to use at the same time to get the most benefit.
The choice of therapy and the dosing schedule will depend on your needs and views. To help decide on the best treatment for you, your healthcare professional will take into account your age, your psoriasis and the affect it is having on you and whether you have psoriatic arthritis or any other conditions. They will also ask if you have any plans to have a baby. Your healthcare professional should explain the risks and benefits of these treatments and healthcare professionals with specific training and competence should provide support and advice on their use.
Before you start systemic therapy, your healthcare professional should offer you the opportunity to be part of a long-term register that records the safety of this type of treatment. When your healthcare professional reviews how your psoriasis has responded to treatment they should take into account:
whether the severity of the disease has changed since treatment started
whether any psoriatic arthritis has been controlled
the impact of your psoriasis on your physical, psychological and social wellbeing
the benefits and risks of continuing treatment
your views (and the views of your family or carers).
Most people should be offered methotrexate tablets as the first choice of systemic drug. Sometimes another tablet called ciclosporin may be offered. If the first drug you try doesn't work well enough, your healthcare professional may suggest changing to the other drug.
If you have psoriatic arthritis, the choice of drug to treat your psoriasis should be decided in consultation with a rheumatologist.
If your psoriasis is severe and has not improved with other treatments you may be offered injections with a systemic biological drug.
If you develop side effects or your psoriasis has not shown an adequate response to systemic biological therapy after 10 to16 weeks the treatment should be stopped and you may be offered treatment with a different biological drug.
If treatment with a second biological drug doesn't work, there should be further discussion with a specialist doctor who has a particular expertise in biological therapy.
NICE has produced the following information for the public on biological drugs that you may find useful:
Ustekinumab for the treatment of adults with moderate to severe psoriasis (see www.nice.org.uk/guidance/TA180/PublicInfo)
Adalimumab for psoriasis (see www.nice.org.uk/guidance/TA146/PublicInfo)
Infliximab for psoriasis (see www.nice.org.uk/guidance/TA134/PublicInfo)
Etanercept and efalizumab for the treatment of psoriasis (see www.nice.org.uk/guidance/TA103/PublicInfo).