Implementation of Recommendations for the Management of Psoriasis During Preconception, Pregnancy, Postpartum, Breastfeeding, and Perinatal Care. / Implementación de las recomendaciones sobre las actuaciones a seguir durante la edad fértil, el embarazo, el posparto, la lactancia y el cuidado perinatal en pacientes con psoriasis.

OBJECTIVE: To analyze degree of implementation of recommendations on the management of psoriasis during preconception, pregnancy, postpartum, breastfeeding, and perinatal care published by the Psoriasis Working Group of the Spanish Academy of Dermatology and Venereology (AEDV). METHODS: We designed a structured online survey consisting of closed questions. A link was emailed to all the members of the Psoriasis Working Group to collect their anonymous responses. We also collected sociodemographic, professional, and practice-related data related to the goals of the study and then compiled descriptive statistics to analyze the survey findings. RESULTS: We received 53 responses for analysis. Overall, 96% of respondents were familiar with the recommendations, but very few of them worked in multidisciplinary maternity care units or had access to specific protocols on the management of psoriasis before, during, and after pregnancy in their departments. Seventy percent of dermatologists regularly ask their patients about pregnancy plans, but only 46% ask both men and women. Women also receive more preconception advice than men (54% vs. 19%). Significant variations were observed in the type of advice given. Ninety percent of the dermatologists interrupt topical treatments during pregnancy, and nearly all suspend conventional systemic drugs with the exception of cyclosporin A. Most biologics are also being discontinued in the third trimester, with the exception of certolizumab pegol. Almost all the respondents indicated that they use topical treatments, phototherapy, and certolizumab pegol in breastfeeding mothers. The main barriers to implementing the working group's recommendations are a lack of time, a lack of support, and a lack of robust data. CONCLUSIONS: Although the AEDV psoriasis working group's recommendations are widely known, areas for improvement remain.

Redefining the therapeutic objective in psoriatic patients candidates for biological therapy.

The advances in psoriasis management currently allow achieving a good control of the disease. In particular, with the latest developed molecules, available evidence suggests that it is possible to pose an ambitious therapeutic goal, such as a Dermatology Life Quality Index 0/1, a Physician Global Assessment 0/1, or a Psoriasis Area and Severity Index 90/100 response. However, patients often fail to achieve the complete clearance of their cutaneous lesions or the improvement of disease factors that impair their quality of life. To optimize the treatment of psoriasis, it is not enough to define precisely the therapeutic objective, but also to adapt the therapeutic strategy to make the necessary modifications in case of not achieving it at the time point (at the end of the induction phase, or every 3-6 months) to be agreed with the patient (the so-called treat-to-target approach). In the present report, based on the Delphi methodology, 11 dermatologists from the Spanish Psoriasis Group addressed key issues that could be involved in the achievement and maintenance of the therapeutic goals of patients with moderate to severe psoriasis. The document provides 27 consensus statements intended to support clinical decision-making by healthcare professionals for patients who might be candidates to receive biologic therapy.

Serie de casos de pacientes psoriásicas expuestas a terapia biológica durante el embarazo. Registro BIOBADADERM y revisión de la literatura / A case series of patients with psoriasis exposed to biologic therapy during pregnancy: the BIOBADADERM register and a review of the literature

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Does the treatment ladder for systemic therapy in moderate to severe psoriasis only go up? The percentage of patients with severe psoriasis on biologics increases over time / Escalera terapéutica en la psoriasis moderada y grave ¿ Sólo hacia arriba?: El porcentaje de pacientes con psoriasis grave tratados con biológicos se incrementa con el tiempo

BACKGROUND: With the advent of biologic drugs in the management of moderate to severe psoriasis, there may have been a shift in therapeutic approach from rotational strategies to a unidirectional progression from topical treatments to the highest rung of the therapeutic ladder. We studied the frequency of switching from classic to biologic therapy and vice versa in a cohort of patients with psoriasis over a period of up to 5 years. METHODS: Patients are included in the BIOBADADERM prospective registry when they are first prescribed any specific conventional or biologic systemic treatment. The data for each patient refer to the follow-up period from the time they entered the cohort until October 2013. To describe the pattern of switches from classic to biologic therapy and vice versa, we used the data in the registry on the first day of every 365-day period following the date each patient was included in the cohort. RESULTS: In total, 47.3% of the patients (926/1956) were prescribed a classic systemic drug and 52.7% (1030/1956) a biologic agent on entry into the study. Of the 741 patients who accumulated 5 years of follow-up, 21.9% (155) were receiving nonbiologic drugs and 78.1% (553) were on biologic therapy on the first day of their 5th year of follow-up. CONCLUSIONS: The proportion of patients receiving biologic therapy increased with longer follow-up

INTRODUCCIÓN: Con el advenimiento de fármacos biológicos en el manejo de la psoriasis moderada a grave, es probable que haya habido un cambio en la actitud terapéutica desde estrategias de rotación a una progresión unidireccional desde tratamientos tópicos al escalón más alta de la escalera terapéutica. Evaluamos la frecuencia del cambio desde el tratamiento clásico al biológico y vice-versa en una cohorte de pacientes con psoriasis durante un periodo de hasta 5 años. MÉTODOS: Los pacientes fueron incluidos en el registro prospectivo de Biobadaderm cuando se les fueron prescritos por primera vez cualquier tratamiento convencional o biológico sistémico. Los datos para cada paciente se refieren al período de seguimiento desde la hora de su inclusión en la cohorte hasta octubre de 2013. Para describir el patrón de cambio desde el tratamiento clásico al biológico y vice-versa, utilizamos los datos en el registro en el primer día de cada periodo de 365 días después de la fecha de inclusión de cada paciente en la cohorte. RESULTADOS: En total, 47,3% de los pacientes (926/1956) fueren prescritos un medicamento sistémico clásico y 52,7% (1030/1956) un biológico al entrar en el estudio. De los 741 pacientes que acabaron 5 años de seguimiento, 21,9% (155) recibieron medicamentos no biológicos y 78,1% (553) recibieron tratamiento biológico en el primera día del quinto año de seguimiento. CONCLUSIONES: La proporción de pacientes recibiendo tratamiento biológico aumento con el seguimiento más prolongado

Recomendaciones de expertos para el tratamiento de la psoriasis en situaciones especiales / Expert recommendations on treating psoriasis in special circumstances

INTRODUCCIÓN Y OBJETIVOS: Existe gran cantidad de información sobre la terapia sistémica y biológica de la psoriasis moderada-grave. Sin embargo, pueden identificarse numerosas situaciones clínicas concretas en las que la evidencia clínica es controvertida y donde resulta útil la opinión consensuada de los expertos. MATERIAL Y MÉTODOS: Un comité científico revisó, de forma sistemática, la bibliografía disponible en 5 escenarios clínicos. En aquellas cuestiones en las que la evidencia era controvertida se llevó a cabo un cuestionario on line según la metodología Delphi, realizado por dermatólogos con experiencia en el manejo de la psoriasis moderada-grave. RESULTADOS: El cuestionario recogió opiniones de 23 dermatólogos y se alcanzó el consenso en 37 de las 66 aseveraciones propuestas (56%). Los resultados permitieron consensuar propuestas en diversas situaciones clínicas, aun cuando la evidencia no fuese firme. Así, tanto el tratamiento intermitente como la desintensificación se consideraron estrategias adecuadas en la optimización de la terapia biológica y en la reducción de costes. La determinación de niveles de fármaco y de anticuerpos antifármaco debería incluirse rutinariamente en el seguimiento de los pacientes psoriásicos tratados con terapia biológica. La coexistencia de artropatía psoriásica y de antecedentes cardiovasculares condiciona la elección de la terapia biológica, prefiriéndose los fármacos anti-TNF alfa como primera elección. En pacientes embarazadas o con deseos de gestación la evaluación personalizada, la gravedad de la psoriasis y la vida media del fármaco son factores relevantes en la toma de decisiones. CONCLUSIONES: La combinación de una revisión sistemática de la literatura y la discusión y opinión estructurada de los expertos permite realizar propuestas para situaciones clínicas concretas

INTRODUCTION AND OBJECTIVES: A great amount of information on systemic and biologic therapies for moderate to severe psoriasis is now available. However, applying the evidence in numerous clinical scenarios has engendered debate; under these circumstances, the consensus of experts is useful. MATERIAL AND METHODS: A scientific committee systematically reviewed the literature relevant to 5 clinical scenarios. An online Delphi survey of dermatologists with experience treating moderate to severe psoriasis was then carried out in order to shed light on questions that remained unresolved by the available evidence. RESULTS: Twenty-three dermatologists responded to the survey and consensus was reached on 37 (56%) of the 66 statements proposed. These results led to consensus on various clinical situations even though firm evidence was lacking. Thus, intermittent therapeutic regimens and strategies for reducing the intensity of treatment are considered appropriate for optimizing biologic treatment and reducing costs. The measurement of drug and antidrug antibody levels should be included routinely when following patients on biologics to treat psoriasis. Concomitant psoriatic arthritis or a history of cardiovascular conditions will influence the choice of biologic; in these situations, an agent with anti-tumor necrosis factor properties will be preferred. Tailored management is important when the patient is pregnant or intends to conceive; drug half-life and disease severity are important factors to take into consideration in these scenarios. CONCLUSIONS: A combination of systematic review of the literature and structured discussion of expert opinion facilitates decision-making in specific clinical scenarios

Expert recommendations on treating psoriasis in special circumstances.

INTRODUCTION AND OBJECTIVES: A great amount of information on systemic and biologic therapies for moderate to severe psoriasis is now available. However, applying the evidence in numerous clinical scenarios has engendered debate; under these circumstances, the consensus of experts is useful. MATERIAL AND METHODS: A scientific committee systematically reviewed the literature relevant to 5 clinical scenarios. An online Delphi survey of dermatologists with experience treating moderate to severe psoriasis was then carried out in order to shed light on questions that remained unresolved by the available evidence. RESULTS: Twenty-three dermatologists responded to the survey and consensus was reached on 37 (56%) of the 66 statements proposed. These results led to consensus on various clinical situations even though firm evidence was lacking. Thus, intermittent therapeutic regimens and strategies for reducing the intensity of treatment are considered appropriate for optimizing biologic treatment and reducing costs. The measurement of drug and antidrug antibody levels should be included routinely when following patients on biologics to treat psoriasis. Concomitant psoriatic arthritis or a history of cardiovascular conditions will influence the choice of biologic; in these situations, an agent with anti-tumor necrosis factor properties will be preferred. Tailored management is important when the patient is pregnant or intends to conceive; drug half-life and disease severity are important factors to take into consideration in these scenarios. CONCLUSIONS: A combination of systematic review of the literature and structured discussion of expert opinion facilitates decision-making in specific clinical scenarios.

Directrices españolas basadas en la evidencia para el tratamiento de la psoriasis con agentes biológicos, 2013. I. Consideraciones de eficacia y selección del tratamiento / Spanish Evidence-Based Guidelines on the Treatment of Psoriasis With Biologic Agents, 2013. Part 1: On Efficacy and Choice of Treatment

La terapia biológica representa una alternativa bien establecida en el manejo de la psoriasis moderada y grave. Sin embargo, su elevado coste, la experiencia relativamente limitada en su empleo clínico y la abundancia de publicaciones existentes hacen necesario el desarrollo de unas directrices basadas en la evidencia científica disponible y en el consenso de un grupo de expertos. El objetivo ideal del tratamiento de la psoriasis es conseguir y mantener a largo plazo un blanqueamiento completo o prácticamente completo o, en su defecto, una mínima afectación localizada y controlable con tratamientos tópicos. Aunque la evidencia disponible permite comparar de forma directa o indirecta la eficacia y las posibilidades de fracaso terapéutico primario o secundario de los diferentes fármacos según parámetros objetivos, las limitaciones en la extrapolación de los ensayos clínicos a la clínica diaria condicionan que la elección del fármaco y de la pauta de administración se realicen de forma individualizada en función de las características de cada paciente. La presente actualización de las directrices para el tratamiento de la psoriasis con agentes biológicos de la Academia Española de Dermatología y Venereología (AEDV) incorpora la información más reciente disponible a este respecto (AU)

Biologic therapy is a well-established strategy for managing moderate and severe psoriasis. Nevertheless, the high cost of such therapy, the relatively short span of clinical experience with biologics, and the abundance of literature now available on these agents have made evidence-based and consensus-based clinical guidelines necessary. The ideal goal of psoriasis treatment is to achieve complete or nearly complete clearing of lesions and to maintain it over time. Failing that ideal, the goal would be to reduce involvement to localized lesions that can be controlled with topical therapy. Although current evidence allows us to directly or indirectly compare the efficacy or risk of primary or secondary failure of available biologics based on objective outcomes, clinical trial findings cannot be directly translated to routine practice. As a result, the prescribing physician must tailor the treatment regimen to the individual patient. This update of the clinical practice guidelines issued by the Spanish Academy of Dermatology and Venereology (AEDV) on biologic therapy for psoriasis incorporates information from the most recent publications on this topic (AU)

Acitretina: guía de uso en psoriasis / Guidelines for the Use of Acitretin in Psoriasis

La fototerapia y los tratamientos sistémicos clásicos (metotrexato, acitetrina, ciclosporina), junto con las denominadas terapias biológicas (etanercept, infliximab, adalimumab, ustekinumab), permiten al dermatólogo disponer de un arsenal terapéutico amplio que aumenta las posibilidades de control de pacientes con psoriasis grave y/o extensa. La acitretina sigue siendo de gran utilidad tanto en monoterapia como combinada con otros fármacos sistémicos (clásicos o «biológicos»), o en terapia secuencial. Se distingue por no ser inmunosupresor directo y mantener respuestas a muy largo plazo, lo que le confiere un papel relevante en el tratamiento de la psoriasis, que no siempre ha sido reconocido en las diversas guías terapéuticas de esta enfermedad. Se presenta una guía de uso de acitretina consensuada por los miembros del Grupo de Psoriasis de la Academia Española de Dermatología y Venereología, en la que se exponen de forma detallada aspectos de la farmacología del fármaco, sus indicaciones y contraindicaciones, su eficacia antipsoriásica, los efectos adversos asociados al fármaco, las acciones a tener en cuenta para aumentar la seguridad de su uso, y se propone diversas estrategias terapéuticas de aplicación en la práctica clínica habitual. El objetivo global es facilitar los criterios de indicación y manejo de la acitretina en pacientes con psoriasis (AU)

Phototherapy, classic systemic treatments (methotrexate, acitretin, and ciclosporin), and biologic agents (etanercept, infliximab, adalimumab, and ustekinumab) constitute a broad therapeutic arsenal that increases the likelihood of achieving control of severe and extensive disease in patients with psoriasis. Acitretin continues to be a very valuable tool in both monotherapy, in which it is combined with other systemic treatments (classic or biologic), and in sequential therapy. Thanks to its lack of a direct immunosuppressive effect and its ability to achieve a long-term response, acitretin has an important role in the treatment of psoriasis, although this has not always been acknowledged in relevant treatment guidelines. We present consensus guidelines for the use of acitretin in psoriasis drawn up by the Psoriasis Group of the Spanish Academy of Dermatology and Venereology. These guidelines provide a detailed account of acitretin, including pharmacological properties, indications and contraindications, adverse effects, and factors that should be taken into account to enhance the safe use of this drug. They also propose treatment strategies for use in routine clinical practice. The overall aim of these guidelines is to define the criteria for the use and management of acetretin in psoriasis (AU)

Guidelines for the use of acitretin in psoriasis. Psoriasis Group of the Spanish Academy of Dermatology and Venereology.

Phototherapy, classic systemic treatments (methotrexate, acitretin, and ciclosporin), and biologic agents (etanercept, infliximab, adalimumab, and ustekinumab) constitute a broad therapeutic arsenal that increases the likelihood of achieving control of severe and extensive disease in patients with psoriasis. Acitretin continues to be a very valuable tool in both monotherapy, in which it is combined with other systemic treatments (classic or biologic), and in sequential therapy. Thanks to its lack of a direct immunosuppressive effect and its ability to achieve a long-term response, acitretin has an important role in the treatment of psoriasis, although this has not always been acknowledged in relevant treatment guidelines. We present consensus guidelines for the use of acitretin in psoriasis drawn up by the Psoriasis Group of the Spanish Academy of Dermatology and Venereology. These guidelines provide a detailed account of acitretin, including pharmacological properties, indications and contraindications, adverse effects, and factors that should be taken into account to enhance the safe use of this drug. They also propose treatment strategies for use in routine clinical practice. The overall aim of these guidelines is to define the criteria for the use and management of acetretin in psoriasis.

Documento de consenso de fototerapia en psoriasis del Grupo Español de Psoriasis: ultravioleta B de banda estrecha (UVBBE), láser y fuentes monocromáticas de excímeros y terapia fotodinámica / Narrowband UV-B, Monochromatic Excimer Laser, and Photodynamic Therapy in Psoriasis: A Consensus Statement of the Spanish Psoriasis Group

Los nuevos conocimientos y estrategias terapéuticas y de manejo de la psoriasis moderada y grave justifican la reevaluación del papel de los tratamientos clásicos en el manejo de estas formas de la enfermedad. En el presente documento se lleva a cabo la evaluación de la terapia ultravioleta B de banda estrecha (UVBBE) considerada en la actualidad, por su relación entre riesgo y beneficio, como la de primera elección en la fototerapia de la psoriasis. Por otra parte, se ha revisado y evaluado la terapia con sistemas y láseres de excímeros y la terapia fotodinámica en la psoriasis. El uso de estas terapias localizadas, aún limitado a pocos centros a escala nacional, constituye una alternativa terapéutica fundamentalmente en formas limitadas y recalcitrantes de psoriasis. En el siguiente documento se evalúan el perfil de eficacia, la seguridad, los esquemas terapéuticos, el tratamiento combinado y diversas consideraciones clínicas en función del perfil del paciente o de las características de la enfermedad (AU)

Novel treatment strategies and new information concerning the management of moderate to severe psoriasis justify a reassessment of the role of the classic therapies in this setting. This consensus statement evaluates narrowband UV-B therapy, which is currently considered the phototherapy option of choice in psoriasis because of its risk-to-benefit ratio. The role of excimer laser and photodynamic therapies are also discussed. These targeted therapies are still only available in a small number of centers in Spain and are used principally in the treatment of localized and recalcitrant forms of psoriasis. We discuss the efficacy and safety of phototherapy as well as treatment regimens, combination therapy, and clinical considerations relating to the characteristics of the patient or the disease (AU)

[Narrowband UV-B, monochromatic excimer laser, and photodynamic therapy in psoriasis: a consensus statement of the Spanish Psoriasis Group]. / Documento de consenso de fototerapia en psoriasis del Grupo Español de Psoriasis: ultravioleta B de banda estrecha (UVBBE), láser y fuentes monocromáticas de excímeros y terapia fotodinámica.

Novel treatment strategies and new information concerning the management of moderate to severe psoriasis justify a reassessment of the role of the classic therapies in this setting. This consensus statement evaluates narrowband UV-B therapy, which is currently considered the phototherapy option of choice in psoriasis because of its risk-to-benefit ratio. The role of excimer laser and photodynamic therapies are also discussed. These targeted therapies are still only available in a small number of centers in Spain and are used principally in the treatment of localized and recalcitrant forms of psoriasis. We discuss the efficacy and safety of phototherapy as well as treatment regimens, combination therapy, and clinical considerations relating to the characteristics of the patient or the disease.

[Combined therapy with etanercept and systemic drugs or phototherapy]. / Terapia combinada con etanercept y fármacos sistémicos o fototerapia.

Biological therapy has been shown to have a very satisfactory antipsoriasic effect. However, this response is not always achieved in all the patients and may be insufficient for others. Thus, strategies have recently been designed, among which the use of combined therapies with biological and systemic drugs or phototherapy have been designed. In this work, we have reviewed the combined therapy with etanercept, systemic drugs and phototherapy and present the case of a patient with psoriasis treated with etanercept and narrow band UVB.

Terapia combinada con etanercept y fármacos sistémicos o fototerapia / Combined therapy with etanercept and systemic drugs or phototherapy

La terapia biológica ha mostrado un efecto antipsoriásico muy satisfactorio; sin embargo, dicha respuesta no siempre se alcanza en todos los pacientes y además puede no resultar suficiente para otros. Por ello, recientemente se han diseñado estrategias entre las que destaca el uso de terapias combinadas con fármacos biológicos y sistémicos o la fototerapia. En este trabajo revisamos la terapia combinada con etanercept, fármacos sistémicos y fototerapia, y presentamos un paciente con psoriasis tratado con etanercept y UVB-BE (AU)

Biological therapy has been shown to have a very satisfactory antipsoriasic effect. However, this response is not always achieved in all the patients and may be insufficient for others. Thus, strategies have recently been designed, among which the use of combined therapies with biological and systemic drugs or phototherapy have been designed. In this work, we have reviewed the combined therapy with etanercept, systemic drugs and phototherapy and present the case of a patient with psoriasis treated with etanercept and narrow band UVB (AU)