Comparison of Management Guidelines for Moderate-to-Severe Plaque Psoriasis: A Review of Phototherapy, Systemic Therapies, and Biologic Agents

J Cutan Med Surg. Mar/Apr 2019;23(2):204-221. doi: 10.1177/1203475418814234. Epub 2018 Nov 21.


Introduction:: Many international guidelines for management of psoriasis exist and most have variations in grading evidence quality, strength of recommendations, and dosing. The objective of our review is to compare international guidelines published in the United Kingdom, Canada, Europe, and the United States for the management of moderate-to-severe plaque psoriasis.

Methods:: We conducted a literature review on systemic therapies and phototherapy for moderate-to-severe plaque psoriasis in adult patients. The British, Canadian, European, and American guidelines served as the key comparators in our review. To identify relevant supporting clinical trials not referenced in the guidelines, we conducted literature searches in PubMed and EMBASE. Two authors independently extracted data on indications, dosing, efficacy, evidence grade, and strength of clinical recommendation for each therapy.

Results:: Monoclonal antibodies directed toward tumour necrosis factor and interleukin (IL)-12/23 received the strongest recommendations for treatment of moderate-to-severe plaque psoriasis, supported by robust, high-quality randomized controlled trials (RCTs). Newer agents such as IL-17 and IL-23 inhibitors are not referenced in most guidelines. There are fewer RCTs for conventional therapies and few head-to-head comparisons with biologics, making it difficult to draw direct comparisons. Among older agents, methotrexate is most strongly recommended for long-term maintenance and cyclosporine is recommended for short-term control of flares.

Conclusion:: Physicians should individualize psoriasis-management strategies based on medication tolerance, efficacy, safety, patient comorbidities, availability of the medication, and patient preference.

Keywords: IL-12/23; IL-17; IL-23; TNF; acitretin; biologics; cyclosporine; guidelines; methotrexate; phototherapy; psoriasis.

Publication types

  • Comparative Study
  • Review

MeSH terms

  • Antibodies, Monoclonal / therapeutic use*
  • Biological Products / therapeutic use*
  • Canada
  • Dermatologic Agents / therapeutic use*
  • Humans
  • Phototherapy*
  • Practice Guidelines as Topic*
  • Psoriasis / therapy*
  • Severity of Illness Index
  • United Kingdom
  • United States


  • Antibodies, Monoclonal
  • Biological Products
  • Dermatologic Agents