Advancing Knowledge. Enhancing Care.
Advancing Knowledge. Enhancing Care.

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2020 EADV | When to Use Classical Systemic Treatment

Systemic therapies 2020

Presented by Rolland Gyulai, MD, PhD

A report from the 29th Congress of the European Academy of Dermatology and Venereology


 Use of classical systemic medications in psoriasis has been decreasing, largely due to biologics and subsequent increased expectation from both patients and dermatologists.1 


Methotrexate (MTX) is widely used and effective, as nearly 42% of patients achieve PASI-75 response on 10-15mg/week dosing, and roughly 50% when dose is intensified to 22.5mg/week.2,3 Given known side effects, careful patient selection is crucial. Dr. Gyulai’s team demonstrated that BMI correlates with liver elastography “fibroscan score,” suggesting obesity is a risk factor, but interestingly cumulative MTX dose does not correlate.4 Subcutaneous injection and closely following guidelines can mitigate risk. Additionally, new data suggest that MTX is immunomodulatory as it restores function of peripheral regulatory T-cells, and that it also exhibits and inhibitory effect on the JAK/STAT pathway.4-6

Acitretin as monotherapy can be quite effective when appropriately dosed, with PASI-50/75 response nearing 90% and 66%, but such therapeutic doses approaching 50mg daily are not routinely prescribed.8,9 Interestingly, gene polymorphisms are associated with responsiveness, which could predict for future responders.10

Less utilized systemics still also play a role in psoriasis, with notable limitations. Cyclosporine can be used safely in the short-term and provides a rapid response; however, response is often short lived as approximately 50% of patients lose efficacy around week 12 in real world databases.11 Fumaric acid exhibits efficacy is similar to MTX (PASI-50 in 64%, PASI-75 in



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