This continuing-education review, the second of a two-part update to a 2019 article, covers systemic therapy for moderate-to-severe psoriasis in groups that clinical trials under-represent: pregnancy, children, hepatitis B and C, HIV and latent tuberculosis, and the hard-to-treat phenotypes — nail, erythrodermic, generalised pustular and palmoplantar psoriasis.
The authors weigh efficacy against monitoring burden, infection and reactivation risk, reproductive plans and phenotype across IL-17, IL-23, IL-36, TNF-α, TYK2 and JAK inhibitors as well as traditional agents. Where comparative data are missing, recommendations are explicitly expert opinion.
It is a narrative review rather than a guideline, so it is most useful as a structured checklist. For Indian practice, where latent tuberculosis and hepatitis B are common and cost limits biologic choice, the infection-screening sections are the parts to keep at hand.
- Screen for latent tuberculosis, hepatitis B, hepatitis C and HIV before starting any biologic or targeted oral agent.
- Discuss pregnancy plans before choosing a systemic; contraception matters for methotrexate and acitretin.
- Match the agent to the phenotype — nail, palmoplantar, pustular and erythrodermic disease respond differently.
- Where evidence is thin, record the reasoning for the choice in the notes.
Why it matters
The patients least represented in trials are the ones where the choice of systemic matters most.
Don't overread it
Recommendations where comparative data are lacking are expert opinion, not trial evidence.
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