AAD-NPF 2019 Joint Guidelines of Care for the Management and Treatment of Psoriasis with Biologics (with Post-Guideline Evidence)
Current AAD-NPF joint guideline on biologic therapy for plaque psoriasis. Read together with post-guideline head-to-head trials (IMMerge, ECLIPSE) and the 2022 FDA approval of oral deucravacitinib (TYK2) informing current biologic class positioning.
What changed in this edition
- Recommends TNF inhibitors, IL-12/23, IL-17, and IL-23 class biologics for moderate-to-severe plaque psoriasis (2019 guideline).
- Baseline tuberculosis (IGRA preferred) and hepatitis B screening required before any biologic initiation.
- Post-guideline head-to-head evidence: risankizumab superior to secukinumab at 52 weeks (IMMerge); guselkumab superior to secukinumab at 48 weeks (ECLIPSE) — supports IL-23 positioning for skin-predominant disease.
- Post-guideline: oral TYK2 inhibitor deucravacitinib FDA-approved 2022 (POETYK PSO-1/2) as an additional oral systemic option.
- Post-guideline: guselkumab approved for active psoriatic arthritis (DISCOVER-2).
- Pediatric biologic approvals expanded since 2019 (ixekizumab, secukinumab, ustekinumab, etanercept).
- Certolizumab pegol remains preferred biologic option in pregnancy given minimal placental transfer.
Clinical takeaways
Choosing a biologic
For skin-predominant disease, IL-23 inhibitors offer durable PASI 90–100 with quarterly dosing. For significant PsA, IL-17 or IL-23 inhibitors both work; TNF inhibitors retain a role with uveitis or IBD overlap.
When to escalate past topicals
Consider biologic or TYK2 when BSA >10%, PASI >10, DLQI >10, or involvement of scalp, palms/soles, genitals, or nails. Do not require prior phototherapy failure.
Monitoring and safety
Baseline TB (IGRA preferred), HBV, HCV, HIV; repeat TB annually in high-risk exposure. No routine labs required long-term for IL-17/IL-23 classes. Deucravacitinib does not require JAK-class lab monitoring.
Comorbidity screening
Screen for PsA at each visit (PEST or similar); counsel on CV risk, MASLD, depression, and IBD. Refer to rheumatology promptly if PsA is suspected.
Pediatrics and pregnancy
Ixekizumab, secukinumab, ustekinumab, and etanercept have pediatric approvals. Certolizumab pegol preferred in pregnancy given minimal placental transfer.
Supporting trials
- IMMergePubMed 32594522
Risankizumab superior to secukinumab for PASI 90 at 52 weeks (86.6% vs 57.1%).
- ECLIPSEPubMed 31402114
Guselkumab superior to secukinumab for PASI 90 at 48 weeks (84% vs 70%).
- POETYK PSO-1PubMed 35820547
Deucravacitinib (oral TYK2) superior to apremilast and placebo for moderate-to-severe plaque psoriasis.
- DISCOVER-2PubMed 32178766
Guselkumab effective for active psoriatic arthritis in biologic-naive patients (ACR20 at week 24).