A Saudi national panel has updated its guidance for moderate-to-severe plaque psoriasis using GRADE methodology, with a systematic search of PubMed, EMBASE and the Cochrane Library covering 2020 to 2026 and 31 PICO questions. The output is 27 evidence-based recommendations and 4 good-practice statements, for adults and children.
Two things stand out. The panel strongly recommends PASI 90 as the primary treatment goal in place of PASI 75 — that is, near-clear rather than substantially improved, which resets when a biologic counts as having failed. For adults, biologic therapy across the IL-17, IL-23, IL-12/23 and TNF-alpha classes is recommended for better disease control. For children, the recommendation is early initiation of biologics, with etanercept, secukinumab, ixekizumab and adalimumab named as preferred options.
This is a national guideline for one country with a psoriasis prevalence around 5.3 per cent, not an international standard, and the drugs it names are not equally accessible everywhere. But the direction matches what the major guidelines have been converging on, and the PASI 90 target is the part that travels: if you are still switching only when PASI 75 is missed, you are working to an older definition of adequate.
- Record PASI at each review and judge response against 90, not 75
- Treat failure to reach PASI 90 on an adequate trial as grounds to switch class, not to wait
- In children with moderate-to-severe disease, raise biologics early rather than after serial conventional failures
- Check which of these agents your patient can actually obtain and afford before setting expectations
- Where biologic access is limited, say so plainly and document the target you are treating to instead
Why it matters
It redefines what counts as an adequate response, and therefore when a biologic has failed.
Don't overread it
This is a national guideline developed for Saudi practice — the drug availability and cost assumptions behind it do not transfer.
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