Summary of treatments for moderate to severe psoriasis. Adapted from British Journal of Dermatology (2004;151 supp 69, pp3-17)

Treatment	Efficacy	Principal Side Effects	Contraindications (not inclusive)	Monitoring*	Long term toxicity
Narrow band ultraviolet B light (310 to 315 nm)²⁰	Induces clearing in 82% of patients	Photodamage, polymorphic light eruption, skin aging, increased risk of skin cancer.	Absolute: Photosensitivity Relative: skin cancer, photosensitising drug therapy	Attendance 2 to 5 times per week for 8 to 12 weeks.	Skin cancer � size of risk not established.
PUVA²⁰	Induces remission in 70% to 90% of patients	Photodamage, skin aging, increased risk of skin cancer, eye damage. Acute effects include nausea, itching and sunburn	Absolute: Photosensitivity Relative: pregnancy, lactation, photosensitising drug therapy, skin cancer, severe organ dysfunction	2 to 4 times per week for ~ 20 treatments. Detailed clinical assessment prior to, during and after therapy	Skin cancer especially when patients subsequently treated with immunosuppressive drugs (eg: ciclosporin); >200 total treatments (or 2000 J/cm²) are not recommended.
Ciclosporin^{20 21}	Highly effective�for example, 75% of patients achieve a score of 75 on the psoriasis area and severity index	Kidney damage, hypertension, immunosuppression	Absolute: Uncontrolled hypertension, impaired kidney function, cancer, HIV Relative:pregnancy, lactation, <18 and >64 years; hypertension, active infection; immunosuppression; nephrotoxic drugs	3 monthly routine bloods; formal renal assessment (eg EDTA clearance) if therapy >6 to 12 months	Skin cancer; other malignancies; irreversible kidney damage Long term therapy not recommended.
Methotrexate^{19 20}	Highly effective�for example, 61% of patients achieve a score of 75 on the psoriasis area and severity index	Bone marrow suppression (commonest cause of methotrexate associated death), liver damage, lung fibrosis.	Absolute: pregnancy, lactation, liver cirrhosis, pregnancy Relative: Liver and kidney disease; blood abnormalities; immunodeficiency; alcohol	3 monthly blood tests; possibly liver biopsy (see text)	Liver damage occurs with prolonged use although the incidence of this varies between individuals.
Acitretin²⁰	Moderately effective	Raised blood lipids; liver damage, dry skin and mucous membranes, hair loss	Absolute: pregnancy (and for 2 years after stopping therapy), lactation Relative: raised blood lipids, osteoporosis and bone abnormalities	3 monthly blood tests	If tolerated, and effective, long term toxicity is minimal
Fumaric acid esters²⁰	Effective but unlicensed in UK and manufactured in Germany.	Abnormal liver tests, white cell count abnormalities (low lymphocytes, high eosinophils); stomach pain/diarrhoea/flushing	Relative: low lymphocyte count; pre-existing stomach or bowel disorders	3 monthly blood tests	If tolerated and effective, long term toxicity is minimal
Hydroxyurea²⁰	Moderately effective but unlicensed for psoriasis.	Bone marrow suppression, rashes, hair loss	Absolute: marked abnormality of bone marrow function Relative: Marked renal damage	1 to 2 monthly blood tests	Long term toxicity includes possible skin cancer and myeloproliferative disorders; bone marrow suppression may occur suddenly

[Author: Please define PASI to make scores meaningful] For brevity, only common and/or clinically significant side effects are mentioned; similarly, contra-indications are not inclusive. *All systemic drug therapy requires intensive clinical and blood monitoring, usually weekly or fortnightly, while establishing an effective, safe dose of treatment.

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