Although the availability of RCTs has dictated that this report deal exclusively with systemic treatments and phototherapies, it is important to be aware that patients with severe psoriasis are frequently treated by means of inpatient or day-treatment centre management (e.g. topical dithranol combined with UVB phototherapy), for which there are no published RCTs. Thus, the recommendation of systemic therapies should not preclude traditional inpatient or day-treatment centre management.
The findings show that there is firm RCT evidence of the effectiveness of some systemic treatments for severe chronic plaque psoriasis, specifically:
- cyclosporin - systemic retinoids (acitretin and etretinate), especially in combination with PUVA - photochemotherapy and phototherapy (PUVA, broadband UVB and narrowband UVB) - combinations of topical vitamin D3 analogues and topical steroids with either photochemotherapy or phototherapy - fumarates.
There is a lack of firm RCT evidence for other treatments for severe chronic plaque psoriasis, including:
- methotrexate, although this widely used treatment was introduced prior to the advent of RCT evidence - hydroxyurea - azathioprine - sulphasalazine, although one RCT showed moderate efficacy.