German evidence-based guidelines for the treatment of Psoriasis vulgaris (short version)

information on how best to apply the treatments described (for full version, please see Nast et al., JDDG, Suppl 2:S1-S126, 2006; or http://www.psoriasis-leitlinie.de).

## O deutsche dermatologische gesellschaft 2007
Abstract Psoriasis vulgaris is a common and chronic inflammatory skin disease which has the potential to significantly reduce the quality of life in severely affected patients. The incidence of psoriasis in Western industrialized countries ranges from 1.5 to 2%. Despite the large variety of treatment options available, patient surveys have revealed insufficient satisfaction with the efficacy of available treatments and a high rate of medication noncompliance. To optimize the treatment of psoriasis in Germany, the Deutsche Dermatologische Gesellschaft and the Berufsverband Deutscher Dermatologen (BVDD) have initiated a project to develop evidence-based guidelines for the management of psoriasis. The guidelines focus on induction therapy in cases of mild, moderate, and severe plaque-type psoriasis in adults. The short version of the guidelines reported here consist of a series of therapeutic recommendations that are based on a systematic literature search and subsequent discussion with experts in the field; they have been approved by a team of dermatology experts. In addition to the therapeutic recommendations provided in this short version, the full version of the guidelines includes information on contraindications, adverse events, drug interactions, practicality, and costs as well as detailed

# Introduction
The Deutsche Dermatologische Gesellschaft (DDG) and the Berufsverband Deutscher Dermatologen (BVDD) have initiated a project to develop evidence-based guidelines for the treatment of plaque psoriasis. The full version of the Guidelines has been published in the Journal der Deutschen Dermatologischen Gesellschaft (JDDG 2006 Suppl 2) and is available at http://www.psoriasis-leitlinie.de [bib_ref] S3-Leitlinie zur Therapie der Psoriasis vulgaris, Nast [/bib_ref]. This article summarizes the key points of the Guidelines.

# Background
Psoriasis vulgaris is a common and chronic inflammatory skin disease which has the potential to significantly reduce the quality of life in severely affected patients. The incidence of psoriasis in Western industrialized countries is 1.5-2% [bib_ref] Psoriasis in the community: prevalence, severity and patients' beliefs and attitudes towards..., Nevitt [/bib_ref]. Studies on the impairment of life quality have shown that, depending on the severity of the disease, a significant burden may exist in the form of a disability or psychosocial stigmatization [bib_ref] Psychosoziale Folgen der Psoriasis-eine empirische Studie uber die Krankheitslast bei 3753 Betroffenen, Schmid-Ott [/bib_ref]. Patient surveys have shown that the mental and physical impairment associated with psoriasis is comparable to that of other significant chronic conditions, such as type 2 diabetes or chronic respiratory diseases [bib_ref] Psoriasis causes as much disability as other major medical diseases, Rapp [/bib_ref].
Patient surveys have shown that only 25% of psoriasis patients are highly satisfied with the outcome of their treatment, another 50% indicate moderate satisfaction, and approximately 20% report low treatment satisfaction [bib_ref] Psoriasis is common, carries a substantial burden even when not extensive, and..., Stern [/bib_ref]. In addition, there is a high non-compliance rate in the intake of medication of up to 40% [bib_ref] Patients with psoriasis and their compliance with medication, Richards [/bib_ref].
Experience has shown that treatment selection for patients with psoriasis vulgaris is more commonly based on traditional concepts than on evidence-based data on the efficacy of various therapeutic options. In addition, it appears that systemic therapies are occasionally not applied in situations where they are needed due to the increased effort involved in monitoring the patients for unwanted side effects and possible interactions with other drugs.

## Goal of the guidelines
The overall objective of the Guidelines is to provide dermatologists in clinics and private practice with an accepted and evidence-based decision-making tool for the selection and implementation of a suitable and efficacious treatment for patients with psoriasis vulgaris. The focus of the Guidelines is on the induction therapy of mild, moderate, and severe plaque-type psoriasis in adults.
1. Physicians' personal experiences and traditional therapeutic concepts should be supplemented and, if necessary, replaced by an evidence-based assessment of the efficacy of individual therapies in psoriasis vulgaris. 2. The guidelines provide in-depth explanations of the available systemic and topical treatments for psoriasis, including the different photo-and photochemical therapies, and provide detailed descriptions of the administration and safety aspects.

## I. kopp
Standige Kommission Leitlinien der AWMF, c/o Philipps-Universitat Marburg, [bib_ref] Psychosoziale Folgen der Psoriasis-eine empirische Studie uber die Krankheitslast bei 3753 Betroffenen, Schmid-Ott [/bib_ref]. By providing background information on the profile of the available drugs, including efficacy, safety, and aspects of practicality and costs, the Guidelines should facilitate the process of selecting an appropriate treatment for each individual patient. This should help increase compliance and optimize the benefit/risk ratio of psoriasis therapies.

# Methods
A detailed description of the methodology employed in developing the Guidelines can be found in the Method Report on the Guidelines (http://www.psoriasis-leitlinie.de).

## Basis of data

## Evidence assessment
The efficacy and effectiveness of each intervention was evaluated using evidence-based criteria. The methodological quality of each individual study was assessed using the following grades of evidence (GE):
A [bib_ref] Patients with psoriasis and their compliance with medication, Richards [/bib_ref] Meta-analysis that includes at least one randomized study with grade A 2 evidence. In addition, the results of the different studies included in the meta-analysis must be consistent with one another. A 2 A high-quality (e.g. sample-size calculation, flow chart, intention-to-treat (ITT) analysis, sufficient size) randomized, double-blind comparative clinical study. B
Randomized clinical study of lesser quality or other comparative study (non-randomized, cohort, or casecontrol study). C Non-comparative study. D Expert opinion.
Individual interventions (i.e., as monotherapy) were rated according to the following levels of evidence (LE):
1. Intervention is supported by studies with grade A 1 evidence or studies with grade A 2 evidence whose results are predominantly consistent with one another. 2. Intervention is supported by studies with grade A 2 evidence or studies with grade B evidence whose results are predominantly consistent with one another. 3. Intervention is supported by studies with grade B evidence or studies with grade C evidence whose results are predominantly consistent with one another. 4. Little or no systematic empirical evidence

## Passages requiring consensus
The Guidelines Group defined particularly relevant sections as passages requiring consensus and approved these in the framework of the consensus conferences. These sections are highlighted in grey boxes.

## Therapeutic recommendation
A distinct rating of the therapeutic options or a strict clinical algorithm cannot be defined for the treatment of psoriasis vulgaris. The criteria for selecting a particular therapy are complex. The decision for a specific treatment should be based on the profile of the available drugs and the characteristics of a given patient. The decision for or against a therapy remains a case-by-case decision. These Guidelines provide a reasonable form of assistance in deciding on a suitable therapy and are an instrument for optimizing the required therapeutic process.
The recommendations formulated in the text are supported graphically in selected key recommendations by the following indications of the strength of the therapeutic recommendation:
[formula]  Measure is highly recommended  Measure is recommended fi Neutral fl [/formula]
Measure is not recommended flfl
Measure is highly inadvisable
The strength of the recommendation reflects both a treatment's efficacy and the level of evidence supporting it as well as aspects of safety, practicality, and the cost/ benefit ratio. A consensus on the strength of the recommendation was reached during the Consensus Conference.

# Results
Therapeutic options are named and discussed in alphabetical order. Overview of the therapeutic options evaluated for chronic plaque psoriasis (the therapeutic options are listed alphabetically and do not represent a ranking)

## Evaluation of topical and systemic therapies in tabular form
These tables are intended to provide a rough orientation for evaluating the therapeutic options. Cumulative calculations of the individual aspects for the overall evaluation of the therapeutic options are not possible and cannot be drawn upon for the final analysis of a therapeutic option. The product assessment for each individual patient may deviate greatly. A direct comparison between systemic and topical therapies is not possible because of the different severity of the psoriasis lesions of patients treated with topical or systemic treatments. The evaluations reported here were made on the basis of data extracted from the literature and expert opinions.
For further details refer to the Methods Report at www.psoriasis-leitlinie.de

## Topical monotherapy
T h e ra p y E ff ic a c y L e v e l o f e v id e n c e S a fe ty /T o le r a n c e in in d u c ti o n th e ra p y S a fe ty /T o le ra n c e in m a in te n a n c e th e ra p y P ra c ti c a li ty (p a ti e n t) P ra c ti c a li ty (p h y s ic ia n ) The evidence level applies only to the estimate of efficacy.
(b) Safety/tolerance in induction therapy or maintenance therapy This refers to the risk of occurrence of severe adverse drug reactions or the probability of adverse drug reactions that would result in the discontinuation of therapy.
(c) Practicality (Patient) This evaluation analyzes the effort involved in handling and administrating the treatment regimen by the patient.
(d) Practicality (Physician) This aspect considers the amount of work (documentation, explanation, monitoring), personnel and equipment needs, time for physician/patient interaction, remuneration of therapeutic measures, invoicing difficulties/risk of recourse claims from the health insurance companies.
(e) Cost/benefit Consideration of the costs of an induction therapy or a maintenance therapy.
The evaluations of safety/tolerance in induction therapy or maintenance therapy as well as practicality for the physician or patient and the cost/benefit were performed using a scale ranging from poor (-) to good (++++). The gradation between these two extremes was made based on expert opinion and unsystematic literature search. A level of evidence was not given for these evaluations since no systematic literature review was performed.

## Evaluation of topical therapies

## Calcineurin inhibitors

## General assessment
Of the three studies with topical calcineurin inhibitors (pimecrolimus, tacrolimus) assessed, one study met the inclusion criteria of the Guidelines. [bib_ref] Topical tacrolimus ointment combined with 6% salicylic acid gel for plaque psoriasis..., Carroll [/bib_ref] For that reason, the efficacy of psoriasis vulgaris treatment with topical calcineurin inhibitors can currently only be rated with a level of evidence of 4. Based on the studies to date, there is no evidence that monotherapy with calcineurin inhibitors is beneficial. Other studies have, however, demonstrated that topical calcineurin inhibitors can be beneficial in the treatment of psoriasis vulgaris in corticosteroid-sensitive areas such as the face, intertriginous areas, and the anogenital region. Since topical calcineurin inhibitors are not approved treatment for psoriasis vulgaris, treatment may only be performed in off-label use. The tolerance is generally good. Data on long-term safety are not available due to the relatively short-period of availability. Broad usage as a first-line therapy does not appear to be justified by the existing data.

## Therapeutic recommendation
Pimecrolimus and tacrolimus administered topically 1 to 2 per day can be considered to be a reasonable supplementary treatment of psoriasis vulgaris at specific locations of the body, such as the face, intertriginous areas and anogenital region (e.g. in interval therapy) or as a replacement for topical corticosteroids.
Watch for unwanted side effects such as burning and skin irritations.
Use at other body sites is not recommended. Other -

## Corticosteroids

## General assessment
Of the 100 studies assessed for a monotherapy with corticosteroids, 20 fulfilled the Guidelines' inclusion criteria. [bib_ref] Combining lesional short-contact dithranol therapy of psoriasis with a potent topical corticosteroid, Swinkels [/bib_ref] [bib_ref] The efficacy and tolerability of clobetasol propionate foam 0.05% in the treatment..., Gottlieb [/bib_ref] [bib_ref] Clinical efficacy and safety of augmented betamethasone dipropionate ointment and diflorasone ointment..., Chuang [/bib_ref] [bib_ref] A comparison of the efficacy and saftey of the combination mometasone furoate..., Katz [/bib_ref] [bib_ref] Mometasone furoate 0.1%-salicylic acid 5% ointment versus mometasone furoate 0.1% ointment in..., Koo [/bib_ref] [bib_ref] Calcitriol shows greater persistence of treatment effect than betamethasone dipropionate in topical..., Camarasa [/bib_ref] [bib_ref] Early onset of action and efficacy of a combination of calcipotriene and..., Papp [/bib_ref] [bib_ref] A new calcipotriol/betamethasone formulation with rapid onset of action was superior to..., Douglas [/bib_ref] [bib_ref] A new calcipotriol/betamethasone dipropionate formulation (Daivobet) is an effective oncedaily treatment for..., Kaufmann [/bib_ref] [bib_ref] Betamethasone valerate foam for treatment of nonscalp psoriasis, Stein [/bib_ref] [bib_ref] Clobetasol propionate lotion in the treatment of moderate to severe plaque-type psoriasis, Decroix [/bib_ref] [bib_ref] A randomized, double-blind, placebo-controlled study of clobetasol propionate 0.05% foam in the..., Lebwohl [/bib_ref] [bib_ref] Comparison of mometasone furoate 0.1% ointment and betamethasone dipropionate 0.05% ointment in..., Peharda [/bib_ref] [bib_ref] Diflorasone diacetate ointment 0.05% versus betamethasone dipropionate ointment 0.05% in moderate-severe plaque-type..., Shupack [/bib_ref] [bib_ref] A comperative study of mometasone furoate oinment and betamethasone valerate ointment in..., Svensson [/bib_ref] [bib_ref] Comparison of hypothalamus-pituitary-adrenal axis suppression from superpotent topical steroids by standard endocrine..., Weston [/bib_ref] [bib_ref] Mometasone furoate 0.1%-salicylic acid 5% ointment twice daily versus fluocinonide 0.05% ointment..., Medansky [/bib_ref] [bib_ref] The use of 0.25% zinc pyrithione spray does not enhance the efficacy..., Housman [/bib_ref] [bib_ref] Management of psoriasis: a clinical evaluation of the dermatological patch, Actidermregistered trade..., Bagatell [/bib_ref] [bib_ref] A comparative multicentre trial of halometasone ointment and fluocortolone plus fluocortolone caproate..., Fabry [/bib_ref] With the application of potent corticosteroids (betamethasone dipropionate, 2 daily), 46-56% of the patients showed a clear improvement or a complete clearing of the skin lesions. Therapy with very potent corticosteroids (clobetasol-17-propionate, 2 daily) demonstrated similar results in 68-89% of the patients in most studies. Topical corticosteroids demonstrate a good to very good efficacy in the treatment of mild to moderate psoriasis vulgaris (LE 1). The combination of topical corticosteroids with salicylic acid enhances the therapeutic effect. Combination with other systemic or topical therapies also results in improved rates of remission. The most common combination is with topical vitamin D 3 derivates. There are no severe adverse drug reactions in the induction phase. Care must be taken regarding the development of typical adverse corticosteroid effects such as skin atrophies or teleangiectases in cases of longer application and in particularly sensitive areas. The practicality for physicians and patients is good.

## Therapeutic recommendation
Therapy with topical corticosteroids is highly recommended for mild to moderate psoriasis vulgaris as a combination therapy with systemic therapies or other topical therapies.
The selection of the class of corticosteroids must be adjusted for the specific skin area to be treated.

## Coal tar

## General assessment
Of 19 studies assessed, four fulfilled the Guidelines' inclusion criteria. [bib_ref] The role of tar in Goeckerman therapy, Belsito [/bib_ref] [bib_ref] Role of ultraviolet A in phototherapy for psoriasis, Diette [/bib_ref] [bib_ref] The effect of topical fluocinonide ointment on phototherapy of psoriasis, Levine [/bib_ref] [bib_ref] Tar gelphototherapy for psoriasis. Combined therapy with suberythemogenic doses of fluorescent sunlamp..., Frost [/bib_ref] Since only one monotherapy study was evaluated (with three patients), it is not possible to make a clear statement about the efficacy of monotherapy (LE 4). Coal tar is used in clinical studies in combination with phototherapy.
In the combination therapy with UV light, a reduction of the PASI by about 75% was achieved in 45-80% of study participants after 15-20 applications. The additional effect of coal tar in combination therapy with UV compared to UV therapy alone has not been proven. The acceptance of coal tar is low due to its color and odor. Magistral preparations may be less expensive than comparable manufactured products.

## Therapeutic recommendation
The efficacy of coal tar treatment in psoriasis vulgaris has not been demonstrated, either as monotherapy or combination therapy. For this reason, coal tar is not recommended for this indication.
In view of the low-risk and more practical therapeutic alternatives, a monotherapy of psoriasis vulgaris with coal tar is obsolete.
Only after careful consideration of the therapeutic benefit and after low-risk therapeutic alternatives have failed should coal tar be used in combination with UVB in exceptional refractory cases of psoriasis vulgaris Arch Dermatol Res (2007) 299: Dithranol

## General assessment
Of 63 studies assessed for a monotherapy with dithranol, 11 fulfilled the Guidelines' inclusion criteria. [bib_ref] A novel liposomal formulation of dithranol for psoriasis: preliminary results, Agarwal [/bib_ref] [bib_ref] Calcipotriol plus short-contact dithranol: a novel topical combination therapy for chronic plaque..., Monastirli [/bib_ref] [bib_ref] Dithranol embedded in crystalline monoglycerides combined with phototherapy (UVB): a new approach..., Gerritsen [/bib_ref] [bib_ref] The impact of the frequency of short contact dithranol treatment, Prins [/bib_ref] [bib_ref] Short-and long-contact therapy using a new dithranol formulation in individually adjusted dosages..., Thune [/bib_ref] [bib_ref] The relevance of salicylic acid in the treatment of plaque psoriasis with..., De Mare [/bib_ref] [bib_ref] Dithranol in a cream preparation: disperse or dissolve?, Prins [/bib_ref] [bib_ref] The efficacy, safety and tolerance of calcitriol 3 microg/g ointment in the..., Hutchinson [/bib_ref] [bib_ref] The effect of initial external glucocorticoid administration on cignolin treatment of psoriasis, Mahrle [/bib_ref] [bib_ref] A comparison between Antraderm stick (0.5% and 1%) and dithranol paste (0.125%..., Agrup [/bib_ref] [bib_ref] Combining lesional short-contact dithranol therapy of psoriasis with a potent topical corticosteroid, Swinkels [/bib_ref] The results of the studies assessed showed total remission (PASI reduction 100%) in 30-70% of the patients and partial remission (PASI reduction 75%) in 26-100% of patients after 5-8 weeks of treatment (LE 2). The efficacy can be increased further if either calcipotriol creams or a UVB phototherapy is combined with dithranol. Dithranol, one of the oldest topical therapeutics for psoriasis vulgaris, is still a treatment for mild to moderate psoriasis vulgaris as an out-patient monotherapy and as part of combination therapies for moderate psoriasis vulgaris in hospitalized and day clinic patients. The therapy is very safe. Although skin irritations, burning, erythema and intermittent brown discolorations are observed, there are no systemic adverse drug reactions. The practicality is clearly limited for outpatient use. The practicality for the physician, especially when treating inpatients, and the costbenefit ratio are positive.

## Therapeutic recommendation

## Monotherapy for patients with mild and moderate psoriasis vulgaris is recommended for induction therapy during hospitalization
And conditionally recommended as an outpatient treatment.
Because it is more practical, short-contact therapy should be given preference. In hospitalized patients, classical dithranol therapy with 2 daily application without immediate rinsing can be easily performed.
The therapy should be performed for 4 and conditionally recommended as an outpatient treatment for 4-8 weeks.
Maintenance or long-term therapy with dithranol is not practical and offers no advantages.
In the treatment of severe forms of psoriasis vulgaris, combination treatment with phototherapy or other topical preparations (calcipotriol) is recommended because of the improved response rate. Other -

## Tazarotene

## General assessment
Of the nine studies assessed, six fulfilled the Guidelines' inclusion criteria. [bib_ref] Tazarotene cream in the treatment of psoriasis: two multicenter, double-blind, randomized, vehicle-controlled..., Weinstein [/bib_ref] [bib_ref] Combination therapy with tazarotene plus a topical corticosteroid for the treatment of..., Gollnick [/bib_ref] [bib_ref] A clinical evaluation of tazarotene 0.1% gel, with and without a high-or..., Green [/bib_ref] [bib_ref] Investigator-masked comparison of tazarotene gel q.d. plus mometasone furoate cream q.d. vs...., Koo [/bib_ref] [bib_ref] Strategies to optimize efficacy, duration of remission, and safety in the treatment..., Lebwohl [/bib_ref] [bib_ref] Tazarotene 0.1% gel in combination with mometasone furoate cream in plaque psoriasis:..., Poulin [/bib_ref] After daily treatment with tazarotene 0.1%, approximately 50% of the patients showed at least a 50% improvement of the skin lesions after about 12 weeks of treatment (LE 2). An optimization of the therapeutic success and a reduction of the frequent skin irritations can be attained with a combination of tazarotene and topical corticosteroids. There are no severe adverse drug reactions. However, contact with healthy skin should be avoided to prevent skin irritation.

## Therapeutic recommendation
The topical application of tazarotene is recommended for the treatment of mild to moderate psoriasis vulgaris.
An application of tazarotene in the evening in combination with a corticosteroid in the morning is recommended as a combination therapy to reduce irritation and increase efficacy.
Vitamin D 3 and analogues

## General assessment
Of the 39 studies considered, 11 fulfilled the Guidelines' inclusion criteria. [bib_ref] The efficacy, safety and tolerance of calcitriol 3 microg/g ointment in the..., Hutchinson [/bib_ref] [bib_ref] Calcitriol shows greater persistence of treatment effect than betamethasone dipropionate in topical..., Camarasa [/bib_ref] [bib_ref] Early onset of action and efficacy of a combination of calcipotriene and..., Papp [/bib_ref] [bib_ref] A new calcipotriol/betamethasone formulation with rapid onset of action was superior to..., Douglas [/bib_ref] [bib_ref] A new calcipotriol/betamethasone dipropionate formulation (Daivobet) is an effective oncedaily treatment for..., Kaufmann [/bib_ref] [bib_ref] Safety and efficacy of combined high-dose treatment with calcipotriol ointment and solution..., Van De Kerkhof [/bib_ref] [bib_ref] Efficacy and safety of a new combination of calcipotriol and betamethasone dipropionate..., Guenther [/bib_ref] [bib_ref] Efficacy of once-daily treatment regimens with calcipotriol/betamethasone dipropionate ointment and calcipotriol ointment..., Kragballe [/bib_ref] [bib_ref] Efficacy of treatment with calcipotriol/betamethasone dipropionate followed by calcipotriol alone compared with..., Ortonne [/bib_ref] [bib_ref] A comparison of tazarotene 0.1% gel once daily plus mometasone furoate 0.1%..., Guenther [/bib_ref] [bib_ref] Calcipotriene ointment and halobetasol ointment in the long-term treatment of psoriasis: effects..., Lebwohl [/bib_ref] The majority of available data is on calcipotriol. After vitamin D 3analogue treatment of mild to moderate psoriasis vulgaris, 30-50% of the patients showed a marked improvement or clearance of the skin lesions within a few weeks (LE 1). The efficacy and tolerance can be further improved if the Vitamin D 3 -analogue is combined with topical corticosteroids during the initial therapy.
In the treatment of severely affected patients, topical therapy with vitamin D 3 -analogues demonstrated synergistic effects with a UV phototherapy and systemic cyclosporine therapy. The topical vitamin D 3 -analogues are generally well-tolerated and practicable for the physician and the patient. Temporary skin irritations may limit the use, especially on the face or the intertriginous areas.

## Therapeutic recommendation
Vitamin D 3 -analogues are the treatment of choice, especially for maintenance therapy in mild to moderate psoriasis vulgaris.
On the basis of the extensive study data and the superior efficacy, this recommendation is particularly true for calcipotriol. Because of its low irritating potential, the application of tacalcitol is particularly recommended for sensitive areas (e.g. face).
In the first weeks, use together with topical corticosteroids or as a fixed combination is superior to monotherapy with respect to efficacy and tolerance.
For moderate to severe psoriasis vulgaris, a combination of topical vitamin D 3 -analogues with UV phototherapy or a systemic therapy can be recommended.

## Phototherapy

## Instructions for application
Pre-treatment
The attending physician has to perform a complete skin examination, paying special attention to melanocytic nevi (especially if dysplastic) and cutaneous malignancies. The patient has to be informed about unwanted side effects and possible long-term risks -especially the therapy-related increased risk of skin cancer. Additional UV exposure as a result of leisure-time activities should be considered. Written informed consent must be obtained. Before starting oral PUVA therapy, an ophthalmologic examination and the prescription of UV sunglasses is required.

## During treatment
The UV dosages applied must be documented in precise physical units (J/cm 2 or mJ/cm 2 ). Regular monitoring of UV erythema must be performed for the purpose of dosage increase. The medical records should document therapeutic response, unwanted side effects, and accompanying treatments. Eye protection with UV glasses is generally required. If the areas chronically exposed to light (face, neck, backs of hands) and the genital region are free of lesions, these should be protected from exposure. Adequate protection from the sun must accompany therapy.

## Post-treatment
Whenever a course of therapy is completed, the cumulative UV dosage and the number of treatments should be recorded and the patient has to be informed. Particularly in the case of patients with high cumulative UV dosage, a regular skin cancer examination should be performed for the patient's entire life.

## General assessment
Of the 145 studies on monotherapy or combination therapy assessed, 25 studies on phototherapy, 32 studies on PUVA therapy, and five studies on therapeutic procedures with lasers fulfilled the Guidelines' inclusion criteria. [bib_ref] The role of tar in Goeckerman therapy, Belsito [/bib_ref] [bib_ref] Role of ultraviolet A in phototherapy for psoriasis, Diette [/bib_ref] [bib_ref] The effect of topical fluocinonide ointment on phototherapy of psoriasis, Levine [/bib_ref] [bib_ref] Tar gelphototherapy for psoriasis. Combined therapy with suberythemogenic doses of fluorescent sunlamp..., Frost [/bib_ref] About three-quarters of all the patients treated with phototherapy attained at least a 75% PASI score reduction after 4-6 weeks, and clearance was frequently achieved (LE 2). Phototherapy represents a safe and very effective modality for the treatment of moderate to severe forms of psoriasis vulgaris. The onset of the clinical effects is within 2 weeks. Of the unwanted side effects, UV erythema from overexposure is by far the most common and is observed frequently. With repeated or long-term application, the consequences of high, cumulative UV dosages (i.e. premature aging of the skin) must be taken into consideration. In addition, carcinogenic risk is associated with oral PUVA and is probable for local PUVA and UVB. The practicality of the therapy is limited as a result of the spatial, financial, and human aspects as well as by time resources on the part of the physician as well as the amount of time required by the patient. From the perspective of the cost-bearing institution, phototherapy has a good cost-benefit ratio. However, the potentially significant costs and time required of the patient must be noted.

## Therapeutic recommendation
Phototherapy is recommended as an induction therapy for moderate to severe psoriasis vulgaris, above all for widespread involvement.
The side effects of specific types of radiation must be weighed. A possible subsequent risk of skin cancer is better documented for PUVA than for UVB. Due to its low practicality and the association of longterm unwanted side effects with the cumulative UV doses, phototherapy is not suitable for long-term treatment.
Combination with topical vitamin D 3 -analogues is recommended to improve the response rate.
A recommendation for the common combination with dithranol and corticosteroids can only be given on the basis of clinical experience, but not on the basis of scientific data.
The use of Excimer Lasers should be limited to the targeted treatment of individual psoriatic plaques.
Arch Dermatol Res (2007) 299: Evaluation of systemic therapies Efalizumab Post-treatment
Patients, who discontinue efalizumab should be subject to close follow-up. In cases of reoccurrence or exacerbation of the disease, the introduction of another suitable psoriasis treatment is recommended.
Patients should be informed about the possibility of the occurrence of a rebound, which would make an immediate consultation necessary. Laboratory controls during treatment with efalizumab a Hb (hemoglobin), HCT (hematocrit), erythrocytes, leukocytes, differential blood count, platelets b ALT alanine aminotransferase, AST aspartate aminotransferase

## General assessment
All six of the studies assessed in terms of the efficacy of therapy with efalizumab fulfilled the Guidelines' inclusion criteria. [bib_ref] Efalizumab for patients with moderate to severe plaque psoriasis: a randomized controlled..., Gordon [/bib_ref] [bib_ref] A novel targeted T-cell modulator, efalizumab, for plaque psoriasis, Lebwohl [/bib_ref] [bib_ref] Extended efalizumab therapy improves chronic plaque psoriasis: results from a randomized phase..., Leonardi [/bib_ref] [bib_ref] Efficacy and safety observed during 24 weeks of efalizumab therapy in patients..., Menter [/bib_ref] [bib_ref] The treatment of moderate to severe psoriasis with a new anti-CD11a monoclonal..., Papp [/bib_ref] [bib_ref] Extended efalizumab therapy sustains efficacy without increasing toxicity in patients with moderate..., Gottlieb [/bib_ref] Approximately 30 and 40% of those patients with moderate to severe psoriasis vulgaris treated with efalizumab at a dose of 1 mg/kg BW per week attained a PASI reduction of > 75% (LE 1) within 12 weeks and 24 weeks, respectively. As a result of the only once-per-week subcutaneous injection and the only rarely required medical controls, the therapy is highly practicable for both the patient and the attending physician. Based on current knowledge, efalizumab possesses a favorable safety profile. A follow-up of a larger patient population for a longer period of time is necessary for a definitive assessment of the efficacy and safety as a long-term treatment. Compared to other biologics, experience with efalizumab is significantly lower due to the smaller patient populations which have been treated with efalizumab. Disease exacerbation during therapy or a rebound after therapy has been observed.

## Therapeutic recommendation
Efalizumab is recommended for induction therapy of moderate to severe psoriasis vulgaris especially if other therapeutic options have not demonstrated sufficient therapeutic effect, are not tolerated, or are contraindicated.
Therapy should not be continued if an improvement of at least 50% of the initial findings is not observed after the first 12 weeks of treatment.

## Etanercept

## ---------------------------------------------------------------------------------------------------------------------------

## Diff. blood count x x x x x ---------------------------------------------------------------------------------------------------------------------------alt, ast x x x x x ---------------------------------------------------------------------------------------------------------------------------pregnancy test x (urine)

## General assessment
Of the four studies assessed, three fulfill the Guidelines' inclusion criteria. [bib_ref] A randomized trial of etanercept as monotherapy for psoriasis, Gottlieb [/bib_ref] [bib_ref] Etanercept as monotherapy in patients with psoriasis, Leonardi [/bib_ref] [bib_ref] Safety and efficacy study on etanercept in patients with plaque psoriasis, Costanzo [/bib_ref] During etanercept therapy, approximately 35% of the patients attained a PASI reduction of 75% after 12 weeks with two subcutaneous doses of 25 mg per week. With a therapy with 2 50 mg subcutaneous per week for 12 weeks approximately 50% of the patients attained a PASI reduction of 75% (LE 1). Clinical experience has shown that clinical efficacy can be maintained in a long-term therapy for up to 24 weeks. The therapy is practicable for both the patient and the physician. As a result of the large number of patients treated with etanercept for other indications, the risk of adverse drug reactions can be estimated very well.

## Therapeutic recommendation
Etanercept is recommended for induction therapy for patients with moderate to severe psoriasis vulgaris, especially if other therapeutic options have not demonstrated satisfactory therapeutic success, are not tolerated, or are contraindicated.
If concomitant psoriasis vulgaris and relevant psoriasis arthritis are present, treatment with TNF-alpha antagonists is particularly recommended.

## Cyclosporine

## General assessment
Of the seven studies evaluated, four fulfill the Guidelines' inclusion criteria. [bib_ref] Infliximab improves signs and symptoms of psoriatic arthritis: results of the IMPACT..., Antoni [/bib_ref] [bib_ref] Infliximab induction therapy for patients with severe plaque-type psoriasis: a randomized, double-blind,..., Gottlieb [/bib_ref] [bib_ref] Efficacy and safety of infliximab monotherapy for plaque-type psoriasis: a randomised trial, Chaudhari [/bib_ref] [bib_ref] Treatment of psoriasis with the chimeric monoclonal antibody against tumor necrosis factor..., Schopf [/bib_ref] Approximately 88% of the patients with moderate to severe psoriasis showed a PASI reduction of 75% after 10 weeks infliximab treatment with a dose of 5 mg/kg BW in the normal therapy intervals (LE 1). Infliximab is currently one of the most effective drugs for the treatment of psoriasis vulgaris. On the basis of the data available from long-term studies, good efficacy is also expected in the long-term therapy of psoriasis vulgaris.
A number of safety aspects should be considered with infliximab. Amongst these are, above all, infusion reactions and the risk of severe infection. This requires a careful evaluation of the indication, education, as well as monitoring of the patient. As a result of the large number of patients treated with infliximab for other indications, the risk of adverse drug reactions can be estimated very well.

## Therapeutic recommendation
Infliximab is recommended for the induction therapy of moderate to severe psoriasis vulgaris and severe, special forms of psoriasis which cannot be controlled by other therapeutic options or if, on the basis of the severity of the disease, a rapid resolution is required.
If concomitant psoriasis vulgaris and relevant psoriasis arthritis are present, treatment with TNF-alpha antagonists is particularly recommended..

## ---------------------------------------------------------------------------------------------------------------------------complete blood count a x prior to start of therapy and before every infusion ---------------------------------------------------------------------------------------------------------------------------ast, alt x prior to start of therapy and before every infusion ---------------------------------------------------------------------------------------------------------------------------

## 5.2.2)
With an uncomplicated long-term therapy with low dose (2.5-3 mg/kg BW daily) control intervals may later be extended to 2 months Short intervals (e.g., in patients with risk factors), dosage increases with the intake of metabolic drugs or with regard to the ADRs of interacting drugs Creatinine clearance in cases of implausible creatinine plasma levels In selected patients with intermittent and short-term treatment, a smaller number of controls (e.g., regular controls of blood pressure and creatinine assay) may be sufficient Determination of the cyclosporine level is recommended in individual cases
Measures after therapy None Fumaric acid esters

## Fumaderm initial fumaderm
Week 1 1-0-0
Week 2 1-0-1
Week 3 1-1-1
Week 4 1-0-0
Week 5 1-0-1
Week 6 1-1-1
Week 7 2-1-1
Week 8 2-1-2
Week 9 2-2-2

## General assessment
Of 65 studies evaluated with respect to the efficacy of a cyclosporine monotherapy in psoriasis, 15 studies fulfilled the Guidelines' inclusion criteria. [bib_ref] Remission of ordinary psoriasis following a short clearance course of cyclosporin, Levell [/bib_ref] [bib_ref] A randomized, double-blind study comparing the efficacy, safety and optimal dose of..., Koo [/bib_ref] [bib_ref] Body-weight-independent dosing of cyclosporine micro-emulsion and three times weekly maintenance regimen in..., Thaci [/bib_ref] [bib_ref] Low-dose short-term cyclosporine versus etretinate in psoriasis: improvement of skin, nail and..., Mahrle [/bib_ref] [bib_ref] Cyclosporine for plaque-type psoriasis. Results of a multidose, double-blind trial, Ellis [/bib_ref] [bib_ref] Efficacy and pharmacokinetics of two formulations of cyclosporine in patients with psoriasis, Elder [/bib_ref] [bib_ref] Ergebnisse einer Cyclosporin-behandlung bei schwerer, chronischer Psoriasis vulgaris, Engst [/bib_ref] [bib_ref] Efficacy and safety of oral cyclosporine A (CYA; Sandimmun) for long-term treatment..., Laburte [/bib_ref] [bib_ref] Lowdose (1,25mg/kg) cyclosporine A: treatment of psoriasis and investigation of the influence..., Meffert [/bib_ref] [bib_ref] Cyclosporine versus etretinate: Italian multicentre comparative trial in severe psoriasis, Finzi [/bib_ref] [bib_ref] Methotrexate versus cyclosporine in moderate-to-severe chronic plaque psoriasis, Heydendael [/bib_ref] [bib_ref] Efficacy of sirolimus (rapamycin) administered concomitantly with a subtherapeutic dose of cyclosporin..., Reitamo [/bib_ref] [bib_ref] A novel therapeutic approach to psoriasis with combination calcipotriol ointment and very..., Grossman [/bib_ref] [bib_ref] Effectiveness of cyclosporine treatment in severe psoriasis: A clinical and immunologic study, Finzi [/bib_ref] [bib_ref] Relapse rates in moderately severe chronic psoriasis treated with cyclosporine A, Higgins [/bib_ref] Cyclosporine demonstrated a high effectiveness in the therapy of adults in these clinical studies. After 12-16 weeks, 50-70% of the patients achieved a PASI 75 (LE 1). Cyclosporine is primarily suited for induction therapy; in long-term therapy a careful and individual weighing of the risks and benefits must be performed due to the adverse drug reactions, especially the nephrotoxicity and increase in blood pressure as well as the possibility of an increased risk of malignancies. With the application of cyclosporine, a variety of drug reactions need to be considered, which on the one hand lead to a change in the availability of cyclosporine or concomitant medications, and on the other hand might increase the risk of adverse drug reactions. As a result of its long-term use for various indications, including psoriasis vulgaris, an extensive body of data is available -also in terms of safety during long-term therapy with cyclosporine. Cyclosporine represents an effective therapy for moderate and severe psoriasis vulgaris.

## Therapeutic recommendation
Cyclosporine is primarily recommended for induction therapy for moderate to severe psoriasis vulgaris in adults who cannot be sufficiently treated with a topical therapy and/or phototherapy. In these cases, there is an acceptable risk-benefit ratio.
Cyclosporine can also be used for the long-term therapy of suitable patients over a period of up to 2 years maximum, whereby an increasing toxicity and a decreasing efficacy should be considered.
A combination with topical preparations for the treatment of psoriasis vulgaris is possible and reasonable, especially because there are signs that combining cyclosporine with topical vitamin D 3 -analogues or corticosteroids may allow a dose reduction of cyclosporine without a loss of efficacy. 

## Instructions for application
Pre-treatment Laboratory controls (see.5.3.3)

## During treatment
Laboratory controls (see.

## 5.3.3)
Post-treatment None

## General assessment
Of 13 studies evaluated, nine fulfilled the Guidelines' inclusion criteria. [bib_ref] Beneficial effects of fumarate therapy in psoriasis vulgaris patients coincide with downregulation..., Litjens [/bib_ref] [bib_ref] Antipsoriatic effect of fumaric acid derivatives. Results of a multicentre double-blind study..., Altmeyer [/bib_ref] [bib_ref] Topical calcipotriol plus oral fumaric acid is more effective and faster acting..., Gollnick [/bib_ref] [bib_ref] Fumaric acid therapy in psoriasis: results and side effects of 2 years..., Kolbach [/bib_ref] [bib_ref] Fumaric acid therapy for psoriasis: a randomized, double-blind, placeFumaric acid therapy for..., Nugteren-Huying [/bib_ref] [bib_ref] Das Wirkungs-und Sicherheitsprofil von Fumarsaureestern in der oralen Langzeittherapie bei schwerer therapieresistenter..., Altmeyer [/bib_ref] [bib_ref] Peroral long-term treatment of psoriasis using fumaric acid derivative, Bayard [/bib_ref] [bib_ref] Fumaric acid esters in the treatment of psoriasis: an Italian experience, Carboni [/bib_ref] [bib_ref] Treatment of psoriasis with fumaric acid esters: results of a prospective multicentre..., Mrowietz [/bib_ref] After 16 weeks, 50-70% of the patients had a PASI 75 (LE 2). There was good efficacy in the induction therapy and in the longterm therapy. The therapy of psoriasis vulgaris with fumaric acid esters represents an effective systemic treatment which demonstrates a high level of long-term safety. The tolerance is limited by adverse gastrointestinal drug reactions and flush symptoms. The risk-benefit analysis of fumaric acid esters is positive, the practicality for both patients and physicians is good, and the costbenefit ratio is acceptable. Positive aspects of the therapy with fumaric acid esters are the low number of drug interactions, the lack of immunosuppressive effects, the absence of increased susceptibility to infection, and the absence of any risk of malignancies during the long-term therapy. A combination with topical medications for the treatment of psoriasis vulgaris is recommendable.

## Therapeutic recommendation
Treatment with fumaric acid esters is recommended as an effective induction therapy for moderate to severe psoriasis vulgaris in adults.
Their application is primarily limited by gastrointestinal ADRs. A combination with any topical drugs for the treatment of psoriasis vulgaris is possible and reasonable.
Because of the favorable risk-benefit profile with good tolerability during long-term therapy, fumaric acid esters are highly recommended.

## Weeks every 8 weeks -------------------------------------------------------------------------------------------------------------------------------

## Instructions for application
Pre-treatment Anamnesis Exclusion of alcohol abuse Physical examination Sonography of liver following indication, i.e., with a positive anamnesis or pathological findings in the physical examination Examine for skin signs of chronic hepatic disease Laboratory controls (see.5.4.2) An assay of the type III procollagen amino terminal propeptide (PIIINP) in serum is recommended Imaging procedures Chest x-ray (as necessary comparative image for the occurrence of pulmonary changes)
Other Information about intake (only on 1 day a week) and early symptoms of potential ADRs

## During treatment
Adequate contraceptive measures (for the treatment of both men and women) Laboratory controls (see.5.4.2) With dosage increases and an increased risk of an elevated MTX concentration (dehydration, reduced renal function, new medications) controls are performed more frequently An assay of type III procollagen amino terminal propeptide (PIIINP) in serum is recommended Liver biopsy: as soon as there is a longer treatment period following a cumulative dose of more than 1.5 g or more or if liver damage is suspected, a hepatologist should be consulted to determine whether a liver biopsy is needed [bib_ref] Fotochemotherapie mit 8-methoxypsoralen und UVA bei Psoriasis vulgaris, Barth [/bib_ref] [bib_ref] Combination of photochemotherapy (PUVA) and ultraviolet B (UVB) in the treatment of..., Park [/bib_ref] Chest x-ray: for complaints such as fever, coughing, dyspnoea, and cyanosis; important: MTX pneumonitis For the general reduction of toxicity, 5 mg per day folic acid can be recommended on the days when there is no MTX intake Careful registration of cumulative dose

## Post-treatment
Reliable contraceptive measures for at least 3 months after therapy in both men and women

## General assessment
Of 11 MTX monotherapy studies assessed for efficacy in psoriasis vulgaris, three studies fulfilled the Guidelines' inclusion criteria. [bib_ref] Methotrexate versus cyclosporine in moderate-to-severe chronic plaque psoriasis, Heydendael [/bib_ref] [bib_ref] Methotrexate for psoriasis. A new therapeutic schedule, Weinstein [/bib_ref] [bib_ref] Methotrexate for psoriasis in weekly oral doses without any adjunctive therapy, Nyfors [/bib_ref]. After a 16-week therapy with MTX, approximately 60-75% of the patients displayed a 75% reduction of the PASI score (LE 3). Clinical experience with MTX is much greater than the documentation of the efficacy and safety of a MTX therapy in clinical studies. Clinical experience has demonstrated that with longer treatment, the efficacy continues to increase and MTX therefore represents, above all, an effective therapeutic option for long-term therapy. The clinical application is restricted by severe ADRs including, in particular, hepatotoxicity, nephrotoxicity, bone marrow suppression, gastrointestinal ulcerations and very rare, but severe idiosyncratic reactions. With precise patient selection, thorough patient information, strict monitoring, administration of the lowest effective dosage (max. 22.5 mg per week) and the additional administration of folic acid or folinic acid, an acceptable safety profile can also be attained for MTX therapy. MTX provides the lowest drug costs per day of all the systemic therapeutics.

## Therapeutic recommendation
MTX is effective in the treatment of moderate to severe psoriasis vulgaris; its use is limited by the contraindications and numerous controls needed during therapy.
MTX is, as a result of its slow onset of action, less recommendable for short-term induction therapy than for long-term therapy.

## -3 months ---------------------------------------------------------------------------------------------------------------------------

## Instructions for application
Pre-treatment Anamnesis Exclusion of pregnancy/nursing a (patient must be informed expressly and extensively about the teratogenic risk of the medication, the necessity of effective and long-term contraception, and the possible consequences of a pregnancy while taking retinoids); written documentation of the patient information interview Alcohol consumption (women of child-bearing age may not drink alcohol during and up to 2 months after treatment with acitretin) Exclusion of alcohol abuse Question regarding bone aches and aches in joints Laboratory controls (see.5.5.2)

## During treatment
With long-term treatment (approximately 1-2 years): radiological control examinations of the spine and joints are recommended if signs and symptoms develop to exclude possible occurrence of ossification Reliable contraception a in women of child-bearing age For women of child-bearing age: No alcohol consumption during therapy Laboratory controls (see. [bib_ref] Psoriasis is common, carries a substantial burden even when not extensive, and..., Stern [/bib_ref] 

## .5.2)
Post-treatment Patients may not donate blood for up to 1 year after the discontinuation of therapy Reliable contraception a in women of child-bearing age up to 2 years after therapy For women of child-bearing age: no alcohol consumption up to 2 months after end of therapy a Double contraception is recommended (e.g., condom + pill; IUD/Nuva-Ring + pill; cave: no low-dosed progesterone preparations/mini-pills) during and up to 2 years after the end of therapy; effectiveness is reduced by acitretin

## General assessment
Of 52 studies assessed, four fulfilled the Guidelines' inclusion criteria in terms of a monotherapy and another four in terms of a combination therapy. [bib_ref] Management of guttate and generalized psoriasis vulgaris: prospective randomized study, Caca-Biljanovska [/bib_ref] [bib_ref] Randomized double-blind multicenter study comparing acitretin-PUVA and placebo-PUVA in the treatment of..., Saurat [/bib_ref] [bib_ref] A double-blind comparison of acitretin and etretinate in combination with bath PUVA..., Lauharanta [/bib_ref] [bib_ref] The effect of addition of calcipotriol ointment (50 micrograms/g) to acitretin therapy..., Van De Kerkhof [/bib_ref] [bib_ref] A double-blind comparison of acitretin and etretinate in the treatment of severe..., Kragballe [/bib_ref] [bib_ref] Sideeffect profile of acitretin therapy in psoriasis, Gupta [/bib_ref] [bib_ref] Efficacy of acitretin and commercial tanning bed therapy for psoriasis, Carlin [/bib_ref] As a result of the very heterogeneous study results, it is not possible to make a clear statement regarding the efficacy of a monotherapy with acitretin (LE 3). The effectiveness of retinoids in lower dosages as a monotherapy in moderate to severe psoriasis vulgaris is not satisfactory. Higher dosages result in an increase of the efficacy, but these are frequently accompanied by increased ADRs in the skin and mucous membranes. In women of childbearing age, the teratogenity, the monthly pregnancy tests, and the need for contraception for up to 2 years after the termination of the therapy severely limit the use of acitretin. An advantage of treatment with retinoids is the synergistic effect in combination with UV light. There is, however, insufficient evidence available on the basis of the studies included to recommend this approach.

## Therapeutic recommendation
Acitretin is not recommended as a monotherapy because of lack of efficacy.
The application of higher dosages, which are more effective, is limited because of frequent adverse drug reactions.
The treatment of plaque psoriasis with acitretin in women of child-bearing age is strongly discouraged.

## Other therapies

## Climate/balneotherapy

## General assessment
Of 33 studies assessed, three fulfilled the Guidelines' inclusion criteria. [bib_ref] Dead sea bath salt for the treatment of psoriasis vulgaris: a double-blind..., Halevy [/bib_ref] [bib_ref] Treatment of psoriasis with 8-methoxypsoralen and sunlight, Robertson [/bib_ref] [bib_ref] Commercial tanning bed treatment is an effective psoriasis treatment:results from an uncontrolled..., Fleischer [/bib_ref]. This translates into a level of evidence 4. The onset of clinical effect and the response rate vary greatly. For that reason, it is not possible to provide exact figures. Balneotherapy and climate therapy have been successfully applied for the treatment of psoriasis vulgaris for centuries and are frequently used in combination with other therapies. These are treatment modalities which have been developed over the years, but for which only very preliminary scientific data are available. In the case of a combined strategy using natural phototherapeutic principles, efficacy and safety are similar to those of simple phototherapy. Balneotherapy and climate therapy are tied to certain geographic regions and the specialized facilities located there.

## Therapeutic recommendation
Balneotherapy and climate therapy have a special place in the framework of the long-term management of psoriasis vulgaris.
The integration of appropriate therapy phases into the treatment concept of patients with psoriasis vulgaris requiring treatment for years can be recommended.
These methods are not indicated for acute treatment or short-term therapy.

## Diagnostics ---------------------------------------------------------------------------------------------------------------------------

## Psychosocial therapy

## General assessment
Of eight studies evaluated, three fulfilled the Guidelines' inclusion criteria. [bib_ref] Influence of a mindfulness meditation-based stress reduction intervention on rates of skin..., Kabat-Zinn [/bib_ref] [bib_ref] A cognitive-behavioural symptom management programme as an adjunct in psoriasis therapy, Fortune [/bib_ref] [bib_ref] A pilot study of hypnosis in the treatment of patients with psoriasis, Tausk [/bib_ref] This resulted in a level of evidence 4. These studies of an additive, psychosocial treatment of psoriasis patients with the evidence grade B or C and with a large random sample selection as well as a relatively large dropout rates do not allow for any final conclusions to be drawn with respect to the efficacy of these therapies. The low number of adverse events is certainly an advantage. With a psychosocial treatment like Psoriasis Symptom Management or patient training, direct effects on skin symptoms can be achieved through, for example, improved stress management, and indirect effects on the development of the psoriasis can be achieved through, for example, improved compliance. These two forms of therapy should be further investigated empirically.

## Therapeutic recommendation
The possible impacts of the disease on social, emotional and psychic aspects should be considered for every psoriatic patient.
Information on existing self-help groups is recommended.
The possibility of participating in a structured training program in accordance with the recommendations of the ADP (Arbeitsgemeinschaft Dermatologische Pravention) of the DDG should be pointed out.
If the suffering is very intense or in cases of repeated clear exacerbation of the psoriasis vulgaris with stress, evaluation by an appropriate specialist with training in psychosomatics or psychotherapy can be offered if the patient so desires and, if necessary, psychosocial therapy initiated.

## Notes on the use of the guidelines
The presentation of the therapies deliberately focused on those aspects deemed particularly relevant by a panel of experts. Aspects which are not of specific importance for a certain intervention, but which are part of the physician's general obligations to the patient, such as the investigation of intolerance and allergies toward certain drugs or the exclusion of contraindications, are not individually listed, but it is nevertheless taken for granted that these are part of the physician's duty to provide care.
It is recommended that each and every user carefully reads and follows the product information and compare it with the recommendations in the Guidelines on dosaging, contraindications, and drug interactions for completeness and currentness. Every dose or application is administered at the user's own risk. The authors and the publishers kindly request that users inform them of any inaccuracies that they might notice. The users are requested to keep themselves constantly informed of any new findings subsequent to the publication of the Guidelines.
[fig] A: systematic search of the literature was carried out in May 2005 with the objective of assessing the effectiveness of individual therapeutic options. This search yielded 6,224 publications of which 142 studies fulfilled the inclusion criteria for the Guidelines (see Box 1) and were therefore included in the assessment of the effectiveness of the relevant treatment. Various other aspects were evaluated on the basis of information presented in available literature, without a systematic analysis, and the years of personal experience of the experts. [/fig]
[fig] -: Complete blood count a [/fig]