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derm.psoriasis.core.v1PRODUCTION
derm.psoriasis.core.v1

Plaque psoriasis (dermatology lens)

dermatologychronicadultpediatric
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame as a CHRONIC immune-mediated (IL-23/Th17) systemic plaque disease managed treat-to-target (NPF: ≤1% BSA or PASI ≤1 at ~3 mo, reassess q6 mo) on a stepwise ladder — NOT a one-off rash. EVERY patient is screened for psoriatic arthritis + the cardiometabolic/MASLD/IBD/mood comorbidity cluster. The dermatologic emergencies (erythrodermic, generalized pustular) and the not-to-miss (CTCL/mycosis fungoides in resistant atypical disease) are recognised here.

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chronic treat-to-target framing set; PsA + comorbidity + emergency + CTCL escape routes noted

Patient inputs (17)

EVERY psoriasis patient is screened for PsA (inflammatory joint/entheseal/back pain, dactylitis) at every visit — early PsA prevents irreversible joint damage (AAD-NPF 2019 comorbidities PMID 30772097)

Psoriasis is a systemic inflammatory disease — screen/co-manage cardiovascular, metabolic syndrome, MASLD, IBD, and depression; comorbidity profile also gates agent choice (AAD-NPF 2019 comorbidities PMID 30772097)

True treatment failure (adequate potency/quantity/duration/adherence) vs under-treatment determines whether to escalate or optimise before stepping up the ladder (AAD-NPF 2020 PMID 32738429)

Sharply demarcated salmon plaque + silvery scale + Auspitz + extensor/scalp/gluteal-cleft distribution is the diagnostic pivot vs the papulosquamous differential (AAD-NPF 2020 PMID 32738429)

>90% BSA confluent erythema = erythrodermic psoriasis — thermoregulatory/fluid emergency, admission threshold (AAD-NPF 2020 PMID 32738429)

Widespread sterile pustules + fever + leukocytosis = generalized pustular psoriasis (von Zumbusch) — emergency; spesolimab (IL-36R) for flares (AAD-NPF 2020 PMID 32738429)

BSA + PGA + special-site involvement + QoL define mild/moderate/severe and gate topical-vs-systemic escalation; treat-to-target uses BSA/PASI (AAD-NPF 2020 PMID 32738429)

Scalp / nail / palmoplantar / genital / inverse disease is high-impact and disproportionately steers escalation independent of total BSA (AAD-NPF 2020 PMID 32738429)

Pediatric dosing + agent age-cutoffs (etanercept ≥4 y, ustekinumab/ixekizumab/secukinumab pediatric labels, apremilast pediatric); pediatric ladder differs (AAD-NPF 2019 pediatric PMID 31703821)

New/worsening psoriasis after β-blocker, lithium, antimalarial, or TNF-inhibitor (paradoxical) → drug-induced/aggravated psoriasis; route derm.drug-eruption.core.v1 (AAD-NPF 2019 comorbidities PMID 30772097)

Fixed, poikilodermatous, atypical, or therapy-resistant "psoriasis" → skin biopsy to exclude mycosis fungoides/CTCL before chronic immunosuppression (AAD-NPF 2019 biologics PMID 30772098)

Latent-TB + hepatitis screen mandatory before TNF / IL-17 / IL-23 / IL-12-23 biologic initiation; active serious infection defers biologic (AAD-NPF 2019 biologics PMID 30772098)

Methotrexate myelosuppression baseline + monitoring; cyclosporine; biologic pre-treatment screen (AAD-NPF 2020 systemic non-biologics PMID 32119894)

Methotrexate hepatotoxicity + MASLD surveillance; acitretin transaminase/triglyceride monitoring (AAD-NPF 2020 systemic non-biologics PMID 32119894)

Cardiometabolic comorbidity surveillance + acitretin/cyclosporine dyslipidaemia monitoring (AAD-NPF 2019 comorbidities PMID 30772097)

Acitretin absolutely contraindicated (teratogenic, 3-year conception ban); methotrexate teratogenic; certolizumab pegol preferred biologic in pregnancy — gates the ladder (AAD-NPF 2020 systemic non-biologics PMID 32119894)

Cyclosporine nephrotoxicity surveillance + methotrexate renal dose-adjust; CKD-EPI 2021 race-free eGFR (AAD-NPF 2020 systemic non-biologics PMID 32119894; Inker NEJM 2021)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationallife_threateningerythrodermic_psoriasis_emergency
    >90% BSA confluent erythema ± scaling with impaired thermoregulation / fluid loss / electrolyte derangement / haemodynamic stress
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninggeneralized_pustular_psoriasis_von_zumbusch
    Acute widespread sterile pustules on erythematous skin with fever, leukocytosis, malaise (von Zumbusch) — often after systemic-steroid withdrawal/taper
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacute_psoriatic_arthritis_dactylitis
    New inflammatory polyarthritis / dactylitis / enthesitis / inflammatory back pain with functional impairment in a psoriasis patient
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepre_biologic_latent_tb_or_serious_infection
    Candidate for biologic/systemic immunosuppression with positive latent-TB screen, active hepatitis B/C, or serious active infection
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepregnancy_systemic_gating
    Pregnant / planning-pregnancy / lactating patient requiring systemic psoriasis therapy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateil17_in_active_inflammatory_bowel_disease
    Candidate for an IL-17 biologic (secukinumab/ixekizumab/brodalumab/bimekizumab) with active or history of inflammatory bowel disease
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateadult_treatment_resistant_biopsy_for_ctcl
    Fixed, poikilodermatous, atypical, or therapy-resistant "psoriasis", especially adult-onset
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmilddrug_induced_or_paradoxical_psoriasis
    New or markedly worsened psoriasis temporally linked to a β-blocker, lithium, antimalarial, or to a TNF-inhibitor (paradoxical psoriasiform eruption)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENToptionalDrives dose adjustment
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Recommended regimen

Plaque psoriasis — stepwise treat-to-target ladder (AAD-NPF 2019/2020)
axis: psoriasis_stepwise_treat_to_target_ladderstep 1 - Step 1 — Topical therapy (mild–moderate; adjunct at any severity)
Selected step "Step 1 — Topical therapy (mild–moderate; adjunct at any severity)" — Mild–moderate plaque psoriasis (<10% BSA, no high-impact special site or PsA), or as a localised adjunct beneath phototherapy/systemic therapy at any severity
  • triamcinolone acetonide
    first line
    mid_potency_topical_corticosteroid
    0.1% cream/ointment • topical • BID to plaques; taper to weekend/proactive (max: lowest effective potency/duration)
    triggers: trunk_extremity_plaques
    AAD-NPF 2020 topicals (PMID 32738429) — potency matched to site/thickness; cornerstone of mild–moderate disease; rotate/combine with vitamin-D analog to limit atrophy and tachyphylaxis.
    rxcui 10759
  • clobetasol propionate
    first line
    high_potency_topical_corticosteroid
    0.05% ointment/foam/solution • topical • BID short burst (≤2-4 wk) (max: avoid face/folds; ≤50 g/wk; limited duration)
    triggers: thick_recalcitrant_plaque, scalp_or_palmoplantar_disease
    AAD-NPF 2020 topicals (PMID 32738429) — superpotent burst for thick/scalp/palmoplantar plaques, then step down to mid-potency + vitamin-D analog maintenance.
    rxcui 21245
  • calcipotriene
    first line
    vitamin_d3_analog
    0.005% cream/ointment/solution • topical • BID (max ~100 g/wk) (max: ~100 g/wk (hypercalcemia risk above))
    triggers: mild_moderate_plaque, steroid_sparing_maintenance
    AAD-NPF 2020 topicals (PMID 32738429) — steroid-sparing maintenance; synergistic with TCS; weekend TCS + weekday vitamin-D analog reduces relapse and atrophy.
    rxcui 29365
  • calcipotriene / betamethasone dipropionate
    first line
    vitamin_d3_analog_corticosteroid_combination
    fixed-combination foam/gel/ointment • topical • once daily (max: per labeling)
    triggers: mild_moderate_plaque, adherence_simplification, scalp_plaque
    AAD-NPF 2020 topicals (PMID 32738429) — fixed-dose combination is more effective than either component and improves adherence; preferred once-daily initial regimen for many plaques incl. scalp.
    rxcui 690419
  • tazarotene
    second line
    topical_retinoid
    0.05–0.1% cream/foam • topical • once daily nightly (max: per labeling; avoid pregnancy)
    triggers: plaque_psoriasis_steroid_sparing, combine_with_tcs_for_irritation
    AAD-NPF 2020 topicals (PMID 32738429) — normalises keratinocyte differentiation; combine with TCS to reduce irritation and boost efficacy; teratogenic (avoid in pregnancy).
    rxcui 83947
  • tacrolimus
    second line
    topical_calcineurin_inhibitor
    0.1% ointment • topical • BID (max: per labeling)
    triggers: facial_disease, intertriginous_inverse_disease, genital_psoriasis, steroid_atrophy_risk
    AAD-NPF 2020 topicals (PMID 32738429) — off-label steroid-sparing for face/folds/genital/inverse psoriasis where TCS atrophy is a concern; transient burning.
    rxcui 42316
  • tapinarof
    second line
    topical_aryl_hydrocarbon_receptor_agonist
    1% cream • topical • once daily (max: per labeling)
    triggers: nonsteroidal_preference, large_bsa_topical_candidate, steroid_sparing
    Non-steroidal AhR-modulating agent (post-guideline FDA-approved); steroid-free option with durable remittive effect; folliculitis/contact dermatitis class effects.
    rxcui 2602286
  • roflumilast
    second line
    topical_pde4_inhibitor
    0.3% cream • topical • once daily (max: per labeling)
    triggers: intertriginous_inverse_disease, nonsteroidal_preference, steroid_sparing
    Non-steroidal topical PDE4 inhibitor (post-guideline FDA-approved); well tolerated on intertriginous/inverse and facial sites; once-daily.
    rxcui 1091836
  • coal tar
    add on
    keratoplastic_antiproliferative
    1–5% preparation/shampoo • topical • daily–several times weekly (max: per preparation)
    triggers: scalp_psoriasis, cost_access_barrier, phototherapy_adjunct_goeckerman
    AAD-NPF 2020 topicals (PMID 32738429) — long-established adjunct, scalp disease, and as a phototherapy adjunct (Goeckerman); cosmetic acceptability limits use.
    rxcui 2635

outpatient playbook — drug actions (4)

  1. 1. calcipotriene-betamethasone (fixed combination) → weekend/proactive maintenance
    rxcui 690419
    fixed-combination • topical • once daily then weekend maintenance
    trigger: Mild–moderate plaque psoriasis (AAD-NPF 2020 PMID 32738429)
    Combination beats either component + improves adherence; weekend maintenance reduces relapse/atrophy
  2. 2. narrowband UVB phototherapy
    protocolised • phototherapy • 2–3×/wk
    trigger: Moderate topical-refractory or systemic-deferred / pregnancy (AAD-NPF 2019 phototherapy PMID 31351884)
    First-line phototherapy; no systemic immunosuppression; pregnancy-compatible
  3. 3. methotrexate + folic acid OR deucravacitinib (oral)
    rxcui 6851
    7.5–15 mg weekly • PO/SC • weekly (MTX) / daily (deucravacitinib)
    trigger: Moderate–severe; biologic not preferred/accessible (AAD-NPF 2020 PMID 32119894)
    MTX also treats PsA; deucravacitinib oral, no boxed JAK warning (POETYK PSO-1 PMID 35820547)
  4. 4. IL-23p19 (guselkumab/risankizumab) first-line biologic; IL-17 if PsA + no IBD; TNF/certolizumab if pregnancy/IBD/PsA
    rxcui 1928588
    per agent • SC • q8–12wk (IL-23) maintenance
    trigger: Severe / special-site / PsA / refractory (AAD-NPF 2019 biologics PMID 30772098)
    IL-23p19 highest skin clearance + durable (VOYAGE 1 PMID 28057360, UltIMMa PMID 30097359); target chosen by comorbidity gating

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Sharply demarcated salmon-pink plaques with adherent silvery scale on extensor surfaces / scalp / gluteal cleft (AAD-NPF 2020 topicals + severity measures PMID 32738429); Nail pitting / onycholysis / oil-drop / subungual hyperkeratosis — a strong psoriasis pivot and PsA risk marker (AAD-NPF 2019 comorbidities PMID 30772097); Chronic relapsing plaque disease with family history of psoriasis — treat-to-target chronic-care entry (AAD-NPF 2019 biologics PMID 30772098).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Plaque psoriasis (dermatology lens)** (derm.psoriasis.core.v1).
Phenotype framing: Terminal papulosquamous differential with named pivots: plaque psoriasis (sharp salmon plaque + silvery scale + Auspitz + nail pits + extensor/scalp/gluteal-cleft pivot) vs atopic/nummular eczema (ill-defined, weeping, flexural, itch-dominant, atopy pivot — route derm.atopic-dermatitis.core.v1) vs tinea corporis (KOH+ annular advancing scale pivot) vs seborrheic dermatitis (greasy scale + scalp/nasolabial pivot) vs mycosis fungoides/CTCL (fixed poikilodermatous + biopsy pivot) vs pityriasis rubra pilaris (cephalo-caudal + islands of sparing + orange keratoderma pivot) vs secondary syphilis (palmoplantar + mucous patches + RPR/TPPA pivot) vs drug-induced/paradoxical psoriasis (β-blocker/lithium/antimalarial/TNF temporal link pivot — route derm.drug-eruption.core.v1) vs cutaneous lupus (photodistribution + ANA + interface biopsy pivot).
Scope: Frame as a CHRONIC immune-mediated (IL-23/Th17) systemic plaque disease managed treat-to-target (NPF: ≤1% BSA or PASI ≤1 at ~3 mo, reassess q6 mo) on a stepwise ladder — NOT a one-off rash. EVERY patient is screened for psoriatic arthritis + the cardiometabolic/MASLD/IBD/mood comorbidity cluster. The dermatologic emergencies (erythrodermic, generalized pustular) and the not-to-miss (CTCL/mycosis fungoides in resistant atypical disease) are recognised here.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Plaque psoriasis — stepwise treat-to-target ladder (AAD-NPF 2019/2020)** — step "Step 1 — Topical therapy (mild–moderate; adjunct at any severity)".
1. triamcinolone acetonide 0.1% cream/ointment topical BID to plaques; taper to weekend/proactive (mid_potency_topical_corticosteroid, first line) — AAD-NPF 2020 topicals (PMID 32738429) — potency matched to site/thickness; cornerstone of mild–moderate disease; rotate/combine with vitamin-D analog to limit atrophy and tachyphylaxis.
2. clobetasol propionate 0.05% ointment/foam/solution topical BID short burst (≤2-4 wk) (high_potency_topical_corticosteroid, first line) — AAD-NPF 2020 topicals (PMID 32738429) — superpotent burst for thick/scalp/palmoplantar plaques, then step down to mid-potency + vitamin-D analog maintenance.
3. calcipotriene 0.005% cream/ointment/solution topical BID (max ~100 g/wk) (vitamin_d3_analog, first line) — AAD-NPF 2020 topicals (PMID 32738429) — steroid-sparing maintenance; synergistic with TCS; weekend TCS + weekday vitamin-D analog reduces relapse and atrophy.
4. calcipotriene / betamethasone dipropionate fixed-combination foam/gel/ointment topical once daily (vitamin_d3_analog_corticosteroid_combination, first line) — AAD-NPF 2020 topicals (PMID 32738429) — fixed-dose combination is more effective than either component and improves adherence; preferred once-daily initial regimen for many plaques incl. scalp.
5. tazarotene 0.05–0.1% cream/foam topical once daily nightly (topical_retinoid, second line) — AAD-NPF 2020 topicals (PMID 32738429) — normalises keratinocyte differentiation; combine with TCS to reduce irritation and boost efficacy; teratogenic (avoid in pregnancy).
6. tacrolimus 0.1% ointment topical BID (topical_calcineurin_inhibitor, second line) — AAD-NPF 2020 topicals (PMID 32738429) — off-label steroid-sparing for face/folds/genital/inverse psoriasis where TCS atrophy is a concern; transient burning.
7. tapinarof 1% cream topical once daily (topical_aryl_hydrocarbon_receptor_agonist, second line) — Non-steroidal AhR-modulating agent (post-guideline FDA-approved); steroid-free option with durable remittive effect; folliculitis/contact dermatitis class effects.
8. roflumilast 0.3% cream topical once daily (topical_pde4_inhibitor, second line) — Non-steroidal topical PDE4 inhibitor (post-guideline FDA-approved); well tolerated on intertriginous/inverse and facial sites; once-daily.
9. coal tar 1–5% preparation/shampoo topical daily–several times weekly (keratoplastic_antiproliferative, add on) — AAD-NPF 2020 topicals (PMID 32738429) — long-established adjunct, scalp disease, and as a phototherapy adjunct (Goeckerman); cosmetic acceptability limits use.

Setting playbook (outpatient) — Confirm clinical plaque psoriasis (exclude papulosquamous mimics + CTCL), screen EVERY patient for psoriatic arthritis + cardiometabolic/MASLD/IBD/mood comorbidity, set a treat-to-target goal (≤1% BSA / PASI ≤1 at ~3 mo), and escalate the stepwise ladder gated on PsA/comorbidity/pregnancy/infection/age (AAD-NPF 2019/2020 PMID 30772098 + 32738429 + 32119894)
10. calcipotriene-betamethasone (fixed combination) → weekend/proactive maintenance fixed-combination topical once daily then weekend maintenance — Mild–moderate plaque psoriasis (AAD-NPF 2020 PMID 32738429) (Combination beats either component + improves adherence; weekend maintenance reduces relapse/atrophy)
11. narrowband UVB phototherapy protocolised phototherapy 2–3×/wk — Moderate topical-refractory or systemic-deferred / pregnancy (AAD-NPF 2019 phototherapy PMID 31351884) (First-line phototherapy; no systemic immunosuppression; pregnancy-compatible)
12. methotrexate + folic acid OR deucravacitinib (oral) 7.5–15 mg weekly PO/SC weekly (MTX) / daily (deucravacitinib) — Moderate–severe; biologic not preferred/accessible (AAD-NPF 2020 PMID 32119894) (MTX also treats PsA; deucravacitinib oral, no boxed JAK warning (POETYK PSO-1 PMID 35820547))
13. IL-23p19 (guselkumab/risankizumab) first-line biologic; IL-17 if PsA + no IBD; TNF/certolizumab if pregnancy/IBD/PsA per agent SC q8–12wk (IL-23) maintenance — Severe / special-site / PsA / refractory (AAD-NPF 2019 biologics PMID 30772098) (IL-23p19 highest skin clearance + durable (VOYAGE 1 PMID 28057360, UltIMMa PMID 30097359); target chosen by comorbidity gating)

Non-pharmacologic actions:
- Treat-to-target plan: NPF goal ≤1% BSA or PASI ≤1 at ~3 mo, reassess q6 mo (AAD-NPF 2019 biologics PMID 30772098)
- Psoriatic-arthritis surveillance + rheumatology referral if positive — early PsA prevents irreversible joint damage (AAD-NPF 2019 comorbidities PMID 30772097)
- Cardiometabolic / metabolic-syndrome / MASLD / IBD / depression screening + risk-factor modification (smoking, alcohol, weight) (AAD-NPF 2019 comorbidities PMID 30772097)
- Trigger counselling — avoid systemic-corticosteroid pulse (rebound/pustular-flare risk) (AAD-NPF 2020 systemic non-biologics PMID 32119894)

AVOID / contraindication checks:
- Acitretin absolutely contraindicated in pregnancy and 3y preconception (AAD NPF 2020 systemic non biologics PMID 32119894 — severe teratogen; women of child bearing potential must avoid conception for 3 years after stopping)
- Methotrexate teratogenic contraindicated in pregnancy and conception (AAD NPF 2020 PMID 32119894 — abortifacient/teratogen; reliable contraception + washout)
- Certolizumab pegol preferred biologic in pregnancy and lactation (AAD NPF 2019 biologics PMID 30772098 — minimal placental transfer)
- Latent tb and hbv screen before any tnf il17 il23 il12 23 biologic (AAD NPF 2019 biologics PMID 30772098)
- Il17 class caution or avoid in active inflammatory bowel disease (AAD NPF 2019 biologics PMID 30772098 — can precipitate/worsen IBD; prefer IL 23p19 or TNF)
- Live vaccines avoided on biologic or systemic immunosuppression (AAD NPF 2019 biologics PMID 30772098)
- Avoid systemic corticosteroid pulse for plaque psoriasis rebound pustular flare (AAD NPF 2020 systemic non biologics PMID 32119894)
- Cyclosporine nephrotoxicity hypertension limit to short term (AAD NPF 2020 PMID 32119894 — ≤1 y; BP + creatinine surveillance)
- Brodalumab rems suicidal ideation behavior mood screen (AAD NPF 2019 biologics PMID 30772098)

Monitoring

Regimen monitoring:
- treat to target BSA PGA PASI QoL at 3mo then q6mo (NPF target ≤1% BSA or PASI ≤1; biologic effect by 12-16 wk) (AAD-NPF 2019 biologics PMID 30772098)
- methotrexate: CBC + LFT periodically + MASLD vigilance; folic acid co-prescribed (AAD-NPF 2020 PMID 32119894)
- cyclosporine: BP + creatinine ~q2wk during titration (calc.ckd epi 2021) (AAD-NPF 2020 PMID 32119894)
- acitretin: LFT + fasting triglycerides; pregnancy-prevention program (AAD-NPF 2020 PMID 32119894)
- biologics: latent-TB/infection surveillance; IL-17 candida + IBD-flare vigilance; brodalumab mood screen (AAD-NPF 2019 biologics PMID 30772098)
- psoriatic arthritis screen and cardiometabolic MASLD mood surveillance each visit (AAD-NPF 2019 comorbidities PMID 30772097)

Setting (outpatient) monitoring:
- Reassess treat-to-target (BSA/PGA/PASI/QoL) at ~3 mo then q6 mo and at each step change (AAD-NPF 2019 biologics PMID 30772098)
- Drug-class safety labs on schedule (MTX CBC/LFT; cyclosporine BP/Cr; acitretin LFT/TG; biologic TB/infection) (AAD-NPF 2020 PMID 32119894; AAD-NPF 2019 biologics PMID 30772098)

Follow-up plan: Chronic-disease maintenance: treat-to-target reassessment q6 mo, proactive topical maintenance to recurrence-prone sites, lifelong PsA surveillance (early referral prevents irreversible joint damage), cardiometabolic / metabolic-syndrome / MASLD / IBD / depression screening and risk-factor modification (smoking, alcohol, weight — AAD-NPF 2019 comorbidities), trigger counselling (avoid systemic-steroid pulse — rebound/pustular flare risk), and step-down/step-up criteria. Dermatology continuity for any systemic agent; reassess CTCL if course remains atypical.
- Close-out criterion: treat-to-target + proactive maintenance + PsA + comorbidity surveillance + trigger education documented

Monitoring phase: Disease: BSA/PGA/PASI + QoL at ~3 mo to judge treat-to-target attainment (≤1% BSA / PASI ≤1), reassess q6 mo and at each step change (biologic effect by 12-16 wk). Drug safety: methotrexate → CBC/LFT periodically + folic acid co-prescribed; cyclosporine → BP + creatinine (via calc.ckd_epi_2021) ~q2wk during titration; acitretin → LFT/triglycerides; biologics → TB/infection surveillance, IL-17 candida/IBD-flare vigilance. Track under-treatment and adherence; cardiometabolic + mood surveillance ongoing.

Disposition

Current setting: outpatient — Confirm clinical plaque psoriasis (exclude papulosquamous mimics + CTCL), screen EVERY patient for psoriatic arthritis + cardiometabolic/MASLD/IBD/mood comorbidity, set a treat-to-target goal (≤1% BSA / PASI ≤1 at ~3 mo), and escalate the stepwise ladder gated on PsA/comorbidity/pregnancy/infection/age (AAD-NPF 2019/2020 PMID 30772098 + 32738429 + 32119894)

Disposition criteria:
- Continue ladder + treat-to-target reassessment + derm follow-up if responding (AAD-NPF 2019 biologics PMID 30772098)
- Step up the ladder if adequate trial fails after adherence/trigger optimisation; switch biologic class if target inadequate
- Admit only for erythrodermic / generalized-pustular psoriasis or serious superimposed infection

Escalation triggers (move to higher acuity):
- Erythrodermic psoriasis (>90% BSA) with thermoregulatory/fluid/haemodynamic compromise → admit (dermatologic emergency)
- Generalized pustular psoriasis (von Zumbusch) with fever/leukocytosis → emergency; spesolimab IL-36R for flare + admit
- Acute polyarticular PsA / dactylitis → urgent rheumatology (route rheum.psoriatic-arthritis.core.v1 — prevent irreversible joint damage)
- Atypical / fixed / treatment-resistant disease → skin biopsy for CTCL before chronic immunosuppression (AAD-NPF 2019 biologics PMID 30772098)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] >90% BSA confluent erythema ± scaling with impaired thermoregulation / fluid loss / electrolyte derangement / haemodynamic stress
- [LIFE_THREATENING] Acute widespread sterile pustules on erythematous skin with fever, leukocytosis, malaise (von Zumbusch) — often after systemic-steroid withdrawal/taper
- [SEVERE] New inflammatory polyarthritis / dactylitis / enthesitis / inflammatory back pain with functional impairment in a psoriasis patient

Citations

- Joint AAD-NPF Guidelines of care for psoriasis: biologics (Menter et al, JAAD 2019; PMID 30772098) + awareness/attention to comorbidities (Elmets et al, JAAD 2019; PMID 30772097) + topical therapy & severity measures (Elmets et al, JAAD 2020; PMID 32738429) + phototherapy (Elmets et al, JAAD 2019; PMID 31351884) + systemic nonbiologic therapies (Menter et al, JAAD 2020; PMID 32119894) + pediatric psoriasis (Menter et al, JAAD 2019; PMID 31703821); landmark trials VOYAGE 1 guselkumab (Blauvelt JAAD 2017; PMID 28057360), UltIMMa-1/2 risankizumab (Gordon Lancet 2018; PMID 30097359), POETYK PSO-1 deucravacitinib (Armstrong JAAD 2022; PMID 35820547), UNCOVER-2/3 ixekizumab (Blauvelt Am J Clin Dermatol 2017; PMID 28074446) [PMID:30772098](https://pubmed.ncbi.nlm.nih.gov/30772098/)
- Cited evidence (PMID 30772097) [PMID:30772097](https://pubmed.ncbi.nlm.nih.gov/30772097/)
- Cited evidence (PMID 32738429) [PMID:32738429](https://pubmed.ncbi.nlm.nih.gov/32738429/)
- Cited evidence (PMID 31351884) [PMID:31351884](https://pubmed.ncbi.nlm.nih.gov/31351884/)
- Cited evidence (PMID 32119894) [PMID:32119894](https://pubmed.ncbi.nlm.nih.gov/32119894/)

Last reconciled with current guidelines: 2026-05-22.
References
  • Joint AAD-NPF Guidelines of care for psoriasis: biologics (Menter et al, JAAD 2019; PMID 30772098) + awareness/attention to comorbidities (Elmets et al, JAAD 2019; PMID 30772097) + topical therapy & severity measures (Elmets et al, JAAD 2020; PMID 32738429) + phototherapy (Elmets et al, JAAD 2019; PMID 31351884) + systemic nonbiologic therapies (Menter et al, JAAD 2020; PMID 32119894) + pediatric psoriasis (Menter et al, JAAD 2019; PMID 31703821); landmark trials VOYAGE 1 guselkumab (Blauvelt JAAD 2017; PMID 28057360), UltIMMa-1/2 risankizumab (Gordon Lancet 2018; PMID 30097359), POETYK PSO-1 deucravacitinib (Armstrong JAAD 2022; PMID 35820547), UNCOVER-2/3 ixekizumab (Blauvelt Am J Clin Dermatol 2017; PMID 28074446) — PMID:30772098
  • Cited evidence (PMID 30772097) — PMID:30772097
  • Cited evidence (PMID 32738429) — PMID:32738429
  • Cited evidence (PMID 31351884) — PMID:31351884
  • Cited evidence (PMID 32119894) — PMID:32119894