PSORIASIS CLINICAL PATHWAY

Adapted from Rizal Medical Center Psoriasis Clinical Pathway

Reviewed by PDS Photodermatology Subspecialty Core Group
 Family history or past history of ADULT PATIENT
PSORIATIC ARTHRITIS OR articular WITH PSORIASIS
symptoms/signs suggestive of
psoriatic arthritis:
1) Joint swelling, 2) Dactylitis, INITIAL Presence of COMORBIDITIES
3) Enthesitis, 4) Nail dystrophy ASSESSMENT (HPN, DM, Obesity, Depression)

(+) Psoriatic * PEST

Arthritis Measure
Refer to Rheumatologist for Disease Refer / Co-manage with
co-management Severity relevant specialty

ther
MILD MODERATE SEVERE ERYTHRODERMIC OR
PSORIASIS PSORIASIS PSORIASIS GENERALIZED
PUSTULAR PSORIASIS

TOPICAL PHOTOTHERAPY
THERAPY +/- Topical Therapy
Failed/Contraindicated/Not available/Not preferred by patient
SYSTEMIC THERAPY
SYSTEMIC THERAPY (Non-biologic) (Non-biologic)
+/- Topical Therapy +/- Topical Therapy
Failed/Contraindicated/Intolerant with PASI >20 or DLQI >20 Failed/Contraindicated/Intolerant

* Psoriasis Epidemiology Screening Tool BIOLOGICS

Ministry of Health. June 2013. Clinical Practice Guidelines:
Management of Psoriasis Vulgaris. Malaysia Health Technology
+/- Topical Therapy
Assessment Section (MaHTAS). Putrajaya Malaysia
DISEASE SEVERITY CLASSIFICATION:
RIZAL MEDICAL CENTER * PDS PHOTODERM SUBSPECIALTY
PSORIASIS CLINICAL PATHWAY (2019) RECOMMENDATIONS (2021)
CLASSIFICATION
Disease Severity
Disease Severity Treatment (Consider the highest Treatment
grading)

PASI <10
TOPICAL TX BSA < 3%
DLQI <10
MILD MILD PASI <5 TOPICAL TX
PASI <10 DLQI <5
DLQI >10
PHOTOTHERAPY BSA 3% - 10%
PASI >10 PHOTOTHERAPY
MODERATE and/or PASI 5 – 10
DLQI <10 and/or
MODERATE SYSTEMIC TX DLQI 5 - 10
+/- TOPICAL TX SYSTEMIC TX
TO SEVERE BSA >10%
PASI >10 +/- TOPICAL TX
SEVERE PASI >10
DLQI >10
DLQI >10
ERYTHRODERMIC or BSA
GENERALIZED DLQI SYSTEMIC TX SYSTEMIC TX
PUSTULAR + PRO +/- TOPICAL TX +/- TOPICAL TX
PSORIASIS + Patient reported outcomes

*Imafuku, S. et al. Asian consensus on assessment and management of mild to moderate plaque psoriasis with topical therapy. Journal of Dermatology 2018
Ministry of Health. June 2013. Clinical Practice Guidelines: Management of Psoriasis Vulgaris. Malaysia Health Technology Assessment Section (MaHTAS). Putrajaya Malaysia
Topical Therapy for Psoriasis:
Trunk and Limbs Scalp
Initial Treatment: Initial Treatment:
* Potent corticosteroid OD-BID X 4 wks Potent corticosteroid solution OD x 4 wks OR
OR Very potent corticosteroid (for rapid response and
* Very potent corticosteroid (for rapid response only for limited plaques) BID x 2 wks Face, Genitals,
& only for limited plaques) OD- BID X 2 wks
OR 2-4 wks Flexures
Potent corticosteroid OD and vitamin D OR If no clearance, near clearance or satisfactory
control after 4 wks consider: Initial Treatment:
vitamin D analogue OD (separately) x 4 wks
• a different formulation of the potent Mild or moderate potency
* VP or P CS Max. 50g/week corticosteroid (for example, a shampoo) and/or corticosteroid BID x 2 wks.
2-4 wks • topical agents to remove adherent scale before
application of the potent corticosteroid. 2 wks
If no clearance, near clearance or satisfactory
4 wks
control, ** vitamin D or a vitamin D analogue
alone BID. ** Max.100g/week If response remains unsatisfactory after a further
4 wks of treatment offer: If the response to short-term
8-12 wks • a combined product containing calcipotriol moderate potency
monohydrate and betamethasone dipropionate corticosteroids is unsatisfactory,
If no clearance, near, clearance or satisfactory OD for up to 4 wks or they require continuous
control after 8–12 wks offer either: treatment to maintain control
4 wks and there is serious risk of local
• combined product: *** calcipotriol monohydrate
and betamethasone dipropionate OD x 4 wks. If continuous treatment for up to 8 wks does not corticosteroid-induced side
*** Max. 15 g daily or 100 g weekly result in clearance, near clearance or satisfactory effects, offer a calcineurin
control offer: inhibitor BID x 4 wks.
Adjunct topicals: Emollients, Tar, Salicylic acid • a very potent corticosteroid solution BID x 2 wks

If treatment is unsatisfactory, please see phototherapy or systemic treatment pathway.

Suggested reassessment : initial review after 4 weeks; treatment unsatisfactory- if no control after 12 weeks
National Institute for Health and Care Excellence (2017) Assessment and Management of Psoriasis (NICE Guideline 153)
Ministry of Health. June 2013. Clinical Practice Guidelines: Management of Psoriasis Vulgaris. Malaysia Health Technology Assessment Section (MaHTAS). Putrajaya Malaysia
Topical Steroid
American
Classification
Phototherapy:
For patients with moderate or severe psoriasis (including subacute to chronic exfoliative dermatitis) ,
OR if topical treatment is unsatisfactory

Persons with guttate or plaque psoriasis

that cannot be controlled with topical Persons with palmoplantar pustulosis
treatments alone

Offer Psoralen with local UVA

Offer Narrowband UV phototherapy.
irradiation (PUVA).
Refer to a phototherapy specialist.
Refer to a phototherapy specialist.

Photodermatology
Directory (PDS Website)

If treatment is unsatisfactory or poorly tolerated;

there is *rapid relapse following completion of treatment;
accessing treatment is difficult for logistical reasons;
or patient is at high risk of skin cancer,
Please see SYSTEMIC pathway.
Suggested reassessment – after 12 weeks
*Rapid relapse is defined as greater than 50% of baseline disease severity within 3 months.
National Institute for Health and Care Excellence (2017) Assessment and Management of Psoriasis (NICE Guideline 153)
Systemic non-biologic therapy:
For patients with moderate or severe psoriasis, or if phototherapy +/- topical tx is unsatisfactory.
All patients who will undergo systemic treatment should have normal baseline screening.
Cyclosporine
Methotrexate
If treatment
• For short term control (e.g. psoriatic flare, Acitretin
• Initial drug of choice is inadequate
erythrodermic, generalized pustular)
• Palmoplantar pustulosis • Pustular psoriasis (1st line)
Dosage: • Considering conception (men and women) • If methotrexate and
Incremental dosing of methotrexate starting Dosage: cyclosporine are not
Use 2.5-3 mg/kg a day of cyclosporin. appropriate or failed
with an initial dose of 5-10 mg once a week
and gradually increase up to an effective dose. Escalate to 5 mg/kg a day after 4 wks only
when there is no response to the lower dose or Dosage
Maximum is 25 mg a week. Use incremental dosing of
when rapid disease control is necessary.
acitretin to minimize
Use the lowest possible therapeutic dose of mucocutaneous side
Use the lowest possible therapeutic dose of
methotrexate to maintain remission. cyclosporine to maintain remission for 1 year. effects and achieve a
Consider other treatment options when disease target dose of 25 mg daily
Supplement with folic acid 5mg once a day relapses rapidly on stopping ciclosporin therapy* in adults. Consider dose
(except the day of methotrexate) or 5mg once a escalation to a maximum
week (the day after methotrexate) Do not use cyclosporine continuously for more of 50 mg OD when no
than 1 year unless disease is severe or unstable other treatment options
and other treatment options, including systemic are available.
Assess tx after 3 months at the target dose
biological therapy, cannot be used.
Assess tx after 4 mons
Please see pathway for monitoring AE. at the target dose
Assess tx after 3 months at the target dose

If treatment is unsatisfactory or poorly tolerated, please see biologics pathway

Suggested reassessment – after 12 weeks
*Rapid relapse is defined as greater than 50% of baseline disease severity within 3 months
Ministry of Health. June 2013. Clinical Practice Guidelines: Management of Psoriasis Vulgaris. Malaysia Health Technology Assessment Section (MaHTAS). Putrajaya Malaysia
National Institute for Health and Care Excellence (2017) Assessment and Management of Psoriasis (NICE Guideline 153)
 Monitoring:
METHOTREXATE:
Repeat complete blood count, AST/ALT, and creatinine within 2 weeks of initiation.
CYCLOSPORINE:
Blood pressure, creatinine, AST/ALT,
complete blood count, serum bilirubin
Monitor CBC, AST/ALT and creatinine
(if clinically indicated), and magnesium
o Every 1 to 2 weeks during dose escalation
monitored monthly
o Monthly for the first 3 months
o Subsequently every 1 to 3 months

Do blood tests 5 - 7 days after last dose of MTX

ACITRETIN:
Get baseline lipid profile and AST/ALT
Consider procollagen III aminopeptide / fibroscan / fibrotest / liver biopsy:
and repeat every 4 - 8 weeks during dose
without risk factors for hepatotoxicity - cumulative dose of 3.5 to 4.0g
escalation, then every 12 weeks
with risk factors for hepatotoxicity – cumulative dose of 1.0 to 1.5g

Thrombocytopenia / Anemia / Neutropenia Raised AST/ALT

STOP TREATMENT & Repeat positive

Refer to Gastroenterologist/
GIVE ALTERNATIVE Hep B / C hepatologist
screening

>3 fold above normal limits of AST/ALT

negative
NO
(+) RISK YES Persistent AST/ALT elevation
FACTORS (>2 fold for 2 to 3 months)
2-3 fold above normal limits of AST/ALT hepatoxicity

Consider procollagen III,

Repeat AST/ALT in 2 to 4 weeks. Persistent elevation in 5 out of 9 fibroscan©, fibrotest / liver biopsy
Decrease dose as needed. AST/ALT in a year Consider other treatment

Ministry of Health. June 2013. Clinical Practice Guidelines: Management of Psoriasis Vulgaris. Malaysia Health Technology Assessment Section (MaHTAS). Putrajaya Malaysia
OTHER SYSTEMIC AGENTS FOR PSORIASIS:
NOTE: These medications are NOT FDA-approved for psoriasis.
May have value for psoriasis in certain instances.

Available in the Philippines Not Available in the Philippines

• HYDROXYUREA • THIOGUANINE
• MYCOPHENOLATE MOFETIL • LEFLUNOMIDE
• AZATHIOPRINE • FUMARIC ACID ESTERS
• TOFACITINIB
• TACROLIMUS • Apremilast – FDA approved,
+ISOTRETINOIN not yet available in the Philippines

Sources:
• Menter A. et al. Joint American Academy of Dermatology National Psoriasis Foundation Guidelines of care for the
management of psoriasis with systemic nonbiologic therapies. JOURNAL OF AMERICAN ACADEMY OF DERMATOLOGY.
JUNE 2020, Vol. 82, No.6:1445-86. https://doi.org/10.1016/j.jaad.2020.02.044

+ Chu S. et al. Oral isotretinoin for the treatment of dermatologic conditions other than acne: a systematic review and
discussion of future directions. ARCHIVES OF DERMATOLOGICAL RESEARCH. NOV. 2020.
doi: 10.1111/1346-8138.14338
 Systemic Biologic Treatment:
For patients with moderate or severe psoriasis, or if other treatment modalities are unsatisfactory.
All patients who will undergo systemic treatment should have normal baseline screening.
Adult with Moderate to Severe Psoriasis
Child/Young: Moderate to Severe Psoriasis
PASI >10 and DLQI >10
Adalimumab, Etanercept, or Ustekinumab Adalimumab, *Etanercept, *Infliximab, Ustekinumab,
(>4y/o) (>6y/o) (>12 y/o) Secukinumab, Guselkumab, Ixekizumab
*with biosimilars

Review Response PASI 50 to 74

PASI < 50 Infliximab (10 wks) and DLQI >5 improvement
Etanercept (12 wks)
Stop Biologic Therapy Secukinumab (12wks) Escalate dose
Consider other biologic Ustekinumab (12 wks) Consider combination w/
Adalimumab (16 wks)
Guselkumab (16 wks)
methotrexate or UVB

PASI 75 OR
PASI >50 + DLQI ≤ 5
Continue Biologic Therapy

Review every 24 weeks

Ministry of Health. June 2013. Clinical Practice Guidelines: Management of Psoriasis Vulgaris. Malaysia Health Technology Assessment Section (MaHTAS). Putrajaya Malaysia
 Baseline Screening for Systemic Treatment:

HISTORY AND EXAMINATION:

For the following established or suspected conditions, clear with

specialist or give alternative treatment:
1) Tuberculosis (TB) (Internal Medicine/ Infectious disease/Pulmonologist)
2) Malignancy
3) Active infection other than TB, HIV-AIDS or viral hepatitis
4) HIV-AIDS (HACT team)
5) Hepatitis B or C
6) Congestive heart failure
7) Demyelinating disease
8) Pregnancy, Desire for pregnancy, or Breast-feeding

Ministry of Health. June 2013. Clinical Practice Guidelines: Management of Psoriasis Vulgaris. Malaysia Health Technology Assessment Section (MaHTAS). Putrajaya Malaysia
 Baseline Screening for Systemic Treatment:
REQUIRED INITIAL LABORATORY TESTS:
• CBC
• AST/ALT
• Creatinine
* Chest X-ray *Screening for TB: If symptomatic or with hx of PTB or any CXR abnormalities in the past
* PPD Test à DO CXR. Otherwise, do PPD Test.

OPTIONAL LABORATORY TESTS, IF CLINICALLY INDICATED:

• ESR/CRP
• Urinalysis
• Lipid profile
• Fasting blood sugar
• Interferon gamma release assay (TB Quantiferon)
• HBsAg – Required prior to biologic use (If positive, refer to a Gastroenterologist)
• Hepatitis B core antibody- If positive, refer to a Gastroenterologist
• HCV Ab - If positive, refer to a Gastroenterologist
• ANA – If positive, to refer to a Rheumatologist
• Urine pregnancy test (UPT)
• COVID-19 TEST (as indicated)

PATIENT EDUCATION & COUNSELING

Ministry of Health. June 2013. Clinical Practice Guidelines: Management of Psoriasis Vulgaris. Malaysia Health Technology Assessment Section (MaHTAS). Putrajaya Malaysia
 Urine Pregnancy Test
Topical medications (as indicated)
Psoriasis Clinic Checklist
Phototherapy (as indicated):
sident MD / Non-biologic systemic
onsultant oral/parenteral medication (as
PATIENTindicated)
EDUCATION :
Biologic medication (as indicated)
Diet / Nutrition
Weight reduction (if necessary)
esident MD
Smoking cessation (if necessary)
Regular exercise
Rheumatology (psoriatic arthritis)
Endocrinology (diabetes mellitus)
Cardiology (hypertension,
esident MD
cardiovascular disease)
Gastroenterology (IBD)
Pulmonology (pulmonary TB)

Ministry of Health. June 2013. Clinical Practice Guidelines: Management of Psoriasis Vulgaris. Malaysia Health Technology Assessment Section (MaHTAS). Putrajaya Malaysia
 RIZAL MEDICAL CENTER
TECHNICAL WORKING GROUP

Francisco D. Rivera IV, Rogelio A. Balagat, MD, Lily Lyralin Laconico Alma Gay C. Martha Joy Bruan- Dr. Ian Cabaluna
MD, FPDS FPCP, FPDS, FPRA Tumalad, MD, FPDS Amado, MD, FPDS Tapales, MD, FPDS
(Chairman, Department (Chairperson, (Epidemiologist)
(Head, Psoriasis Unit) (Co-head, (Head,
of Dermatology) Department of
Phototherapy Unit) Pharmacovigilance
Internal Medicine,
Unit)
Head, Rheumatology-
Dermatology Unit)
 PDS PHOTODERMATOLOGY
SUBSPECIALTY CORE GROUP

Leilani Senador, MD, FPDS Bernadette Arcilla, MD, FPDS Lorna Frez, MD, FPDS Vermen Verallo- Rowell, Patricia Tinio, MD, FPDS Bernardita Policarpio, Deana Ramiscal, MD, FPDS
(Chair 2021 -2022) (Head, Service Committee) MD, FPDS MD, FPDS

Vanessa Carpio, MD, FPDS Lyra Tumalad, MD, FPDS Giselle Ver, MD, FPDS Weena Sabido, MD, FPDS Luella Alcos, MD, FPDS Angel Hernandez, MD, FPDS

Ria Siccion, MD, FPDS Anna Lou Diaz, MD, FPDS Jasmin Yason, MD, FPDS Corrine Sison- De Jesus, MD, DPDS Iza Encarnacion, MD, DPDS Angeli Torres, MD, DPDS
References:
• Ministry of Health- Malaysian Clinical Practice Guideline on the Management of Psoriasis
Vulgaris (2013)

• National Institute for Health and Clinical Excellence (NICE) Guideline for the Assessment
and Treatment of Psoriasis (last updated: September 2017)

• Imafuku, S. et.al. Asian consensus on assessment and management of mild to moderate

plaque psoriasis with topical therapy. Journal of Dermatology 2018

• Menter A. et.al. Joint American Academy of Dermatology National Psoriasis Foundation

Guidelines of care for the management of psoriasis with systemic nonbiologic therapies.
Journal of American Academy of Dermatology. June 2020, Vol. 82, No.6:1445-86.
https://doi.org/10.1016/j.jaad.2020.02.044

• Chu S. et.al. Oral isotretinoin for the treatment of dermatologic conditions other than
acne: a systematic review and discussion of future directions. Archives of Dermatological
Research Nov 2020. doi: 10.1111/1346-8138.14338