From the Medical Board of the National Psoriasis Foundation: Perioperative management of systemic immunomodulatory agents in patients with psoriasis and psoriatic arthritis

J Am Acad Dermatol. 2016 Oct;75(4):798-805.e7. doi: 10.1016/j.jaad.2016.06.014. Epub 2016 Jul 25.


Treatment with systemic immunomodulatory agents is indicated for patients with moderate to severe plaque psoriasis and psoriatic arthritis. In these patients, surgery may confer an increased risk of infectious or surgical complications. We conducted a literature review to examine studies addressing the use of methotrexate, cyclosporine, and targeted immunomodulatory agents (tumor necrosis factor-alfa inhibitors, interleukin [IL]-12/23 inhibitors, IL-17 inhibitors) in patients undergoing surgery. We examined 46 total studies; the majority were retrospective studies in patients with rheumatoid arthritis and inflammatory bowel disease. One study in patients with psoriasis and psoriatic arthritis reviewed 77 procedures and did not find an elevated risk of postoperative complications with tumor necrosis factor-alfa and IL-12/23 inhibitors even with major surgeries. Based on level III evidence, infliximab, adalimumab, etanercept, methotrexate, and cyclosporine can be safely continued through low-risk operations in patients with psoriasis and psoriatic arthritis. For moderate- and high-risk surgeries, a case-by-case approach should be taken based on the patient's individual risk factors and comorbidities.

Keywords: biologic; cyclosporine; immunosuppressant; methotrexate; perioperative; psoriasis; psoriatic arthritis; tumor necrosis factor-alfa inhibitor.

Publication types

  • Review

MeSH terms

  • Arthritis, Psoriatic / diagnosis
  • Arthritis, Psoriatic / drug therapy*
  • Arthritis, Psoriatic / surgery
  • Female
  • Humans
  • Immunologic Factors / pharmacology
  • Immunologic Factors / therapeutic use*
  • Immunomodulation*
  • Male
  • Patient Safety
  • Perioperative Care / methods
  • Practice Guidelines as Topic
  • Prognosis
  • Psoriasis / diagnosis
  • Psoriasis / drug therapy*
  • Psoriasis / surgery
  • Risk Assessment
  • Societies, Medical
  • Specialty Boards
  • Surgical Procedures, Operative / methods*
  • Treatment Outcome


  • Immunologic Factors