Psoriasis in solid organ transplant patients: best practice recommendations from The Medical Board of the National Psoriasis Foundation

Figures & data

Table 1. Therapy for mild-moderate psoriasis in OTR population.

Topical therapy	Topical corticosteroids
First line	Combination agents (calcipotriol/betamethasone)
	Vitamin D analogs (calcipotriol, calcipotriene)
Second line	Tacrolimus ointment or pimecrolimus cream (Preferably used short, not long-term, can be used if failure of other topicals or for areas that are intolerant to topical steroids)
	Tazarotene
	Tar-based therapy

Table 2. First-line therapy for moderate–severe psoriasis in OTR population.

Therapy	Comment
Acitretin and NBUVB	NBUVB best used in Fitzpatrick skin types III-VI
NBUVB alone	If acitretin not indicated or intolerant. Addition of topical tazarotene 0.1% gel or vitamin D3 analogs may increase efficacy and decrease overall UV exposure
Acitretin	In combination with topical calcipotriol increases efficacy. Avoid with severe liver or renal dysfunction or uncontrolled hyperlipidemia

Table 3. Contraindicated for psoriasis in OTR population.

Therapy	Comment
PUVA	May increase NMSC risk

Table 4. Second-line therapy for moderate-to-severe psoriasis in OTR population.

Therapy	Comment
Suggest to transplant surgeon to increase current dose antirejection drugs (CsA, tacrolimus, mycophenolate mofetil (MMF)) or switch to mTOR inhibitors (sirolimus and everolimus)	CsA avoid in renal transplants Tacrolimus preferred over CsA Tacrolimus with MMF instead of azathioprine (which is photosensitizing) mTOR inhibitors switch is instituted no less than 6 months post-transplant in recipients with stable graft function

Table 5. Third-line therapy for moderate-to-severe/refractory psoriasis in OTR population.

Therapy	Comment
Apremilast	Avoid with strong CYP3A4 inducers and severe renal impairment
Ustekinumab	PSOLAR data indicate low risk of infections and cancer in nontransplant psoriasis population
Secukinumab, ixekizumab, or brodalumab	Lack of data for IL-17 inhibitors
Etanercept, adalimumab, or infliximab	TNFI’s may increase SCC risk therefore adding acitretin when possible is advised
Methotrexate	Avoid in liver transplant patients, caution in renal transplant patients