Although biologic therapies broadly gather much attention in discussions of systemic treatments for psoriasis, those who diagnose and treat this common inflammatory skin condition should not overlook other systemic treatments used to manage it.

Speaking at the DEF Biologic & Small Molecule Regional NP/PA CME Virtual Bootcamp in Philadelphia this month, April Armstrong, MD, MPH reviewed several oral agents used to treat psoriasis.

When it comes to methotrexate, Dr. Armstrong says that studies have shown that about one-third of patients on the drug achieve PASI 75 within 16 weeks. She cautions, however, the onset of response is relatively slow for methotrexate and that patients may expect to wait for at least six weeks before they begin to see notable improvement. One update is that we are moving away from liver biopsy to assess hepatotoxicity; rather, in patients with risk factors for hepatic toxicity, newer recommendation suggest non-invasive measures such as liver elastography. Although oral administration is common, methotrexate may be provided via subcutaneous injection. Such administration is associated with better bioavailability and tolerability, compared to oral administration. Regardless of the route of administration, prescribers must be aware of known risks and monitor patients appropriately.

Dr. Armstrong also talked about another oral treatment, apremilast, which is FDA-approved for both psoriasis and psoriatic arthritis. After a six-day dose escalation protocol, treatment is maintained with 30mg apremilast BID. In patients with severe renal impairment, treatment at a dose of 30mg QD may be maintained. What’s new about apremilast is that it is also approved for treating oral ulcers in patients with Bechet’s disease.

Dr. Armstrong, Associate Dean for Clinical Research at University of Southern California, tends to view cyclosporine as a treatment option for the “crisis patient.” Its rapid onset of action may be appropriate for patients with erythrodermic psoriasis, severe pustular psoriasis, or plaque psoriasis, for example. The treatment may also be used as a bridge to other long-term therapies, such as biologics. Importantly, treatment with cyclosporine should be tapered and not stopped abruptly. Dr. Armstrong says that about 70 percent of patients with psoriasis treated with cyclosporine will be clear or almost clear in eight to 16 weeks at a dose of 5mg/kg/day. Prescribers must be aware of baseline and ongoing lab monitoring requirements with cyclosporine.

The next DEF Biologic & Small Molecule RegionalNP/PA CME Bootcamp is scheduled for October in Scottsdale, AZ and is free to registrants to participate. The DEF Regional Biologic Bootcamp CME Program is approved for AMA PRA Category I credit through joint providership of the DEF, Physician Resources, LLC and Evolve Medical Education, LLC. Each program is estimated to be 7 hours of CME/CE credits with a total of 21.0 hours for the Biologic Bootcamp Series. Faculty for the Bootcamps include April Armstrong, MD, MPH, David Cohen, MD, MPH, Joseph Gorelick, MSN, FNP-C, and Kara Gooding, MMS, PA-C. For more information, visit