Researchers Review Practice Guidelines for Biologics in Psoriasis

Guidelines on the use of biologic drugs in patients with psoriasis were mostly seen as having medium-to-high quality; however, investigators said that more work needs to be done to ensure applicability to clinical practice.

The quality of clinical practice guidelines (CPGs) for biologic medications used to treat psoriasis was determined to be medium to high; however, more attention needs to be paid to guideline development applicability, according to a recent analysis.

The systematic literature review, published in the Journal of Dermatological Treatment, is one of the first pieces of evidence evaluating biologic therapy recommendations in psoriasis CPGs, showing that despite near consistency, several domains in the guidelines need improvement.

As biologic treatments for psoriasis have expanded greatly in recent years, there has been a growing number of guidelines being developed for psoriasis. CPGs are considered important tools in influencing clinician and patient choices on whether to pursue a biologic therapy. However, the rise in the number of guidelines has created confusion for decision makers and may provide conflicting recommendations.

The reviewers evaluated the methodological quality of the CPGs using the second edition of the Appraisal of Guidelines for Research and Evaluation instrument, which consists of domains to be rated on a scale from 1 to 7, with a higher score correlating with higher quality. The 6 domains analyzed were:

  • Scope and Purpose
  • Stakeholder Involvement
  • Rigor of Development
  • Clarity of Presentation
  • Applicability
  • Editorial Independence

After each domain was scored, the investigators classified the CPGs based on whether they should be recommended for practical use, categorizing them as “recommended” (mean score ≥ 60%), “recommended with modifications” (mean score 30%-60%), or “not recommended” (mean score ≤ 30%).

On February 19, 2020, the investigators searched 7 computerized databases, 15 guideline databases, and 4 online book malls for articles on CPGs for psoriasis recommendations. Out of the 16,719 articles that were identified, 51 evidence-based CPGs primarily for psoriasis published by medical organizations were included in the analysis.

The articles were produced by 23 agencies from 16 countries and regions and were published from 2004 to 2020. European organization developed 21.57% of the CPGs and the United States produced 15.69%. Eleven CPGs focused on psoriasis vulgaris and plaque psoriasis, 14 were specific to psoriatic arthritis, 3 were for pustular psoriasis, 1 was for erythrodermic psoriasis, and 4 were for psoriasis comorbidities.

The overall quality of the CPGs achieved an average score of 55%, ranging from 29% to 83% across domains. The highest scoring domains were Scope and Purpose (70%), Clarity of Presentation (68%), and Editorial Independence (60%). The other 3 domains had mean scores below 50%, with Applicability scoring the lowest.

“This should remind physicians and health policy makers to present ‘applicability’ as a critical issue when developing CPGs. CPGs can only have an impact when they are applied in clinical practice. However, there is often a gap between the development of clinical guidelines and their implementation. To bridge this gap and improve applicability, developers should provide methods and advice for implementation,” wrote the investigators.

Eighteen (35.29%) CPGs were classified as recommended, 32 (62.75%) were classified as recommended with modifications, and 1 (1.96%) was deemed inadequate.

A total of 95 recommendations containing biologic agents were extracted from the recommended CPGs. Three biologics agents, adalimumab (Humira), ustekinumab (Stelara), and secukinumab (Cosentyx), were recommended for use in adult patients with psoriasis and 3, adalimumab, etanercept (Enbrel), and ustekinumab, were recommended for use in children with psoriasis.

Study limitations included that some of the CPGs were published without methodological documentation and the analysis was restricted to CPGs that were published in English or Chinese.


Xie X, Wang Y, Yao S, et al. Biologics recommendations for patients with psoriasis: a critical appraisal of clinical practice guidelines for psoriasis. J Dermatol Treat. Published online April 13, 2021. Accessed April 23, 2021. doi: 10.1080/09546634.2021.1914306