title: Expert Recommendations on Treating Psoriasis in Special Circumstances (Part II).
abstract: BACKGROUND
  There is insufficient information on how best to treat moderate to severe psoriasis in difficult clinical circumstances.
  
  
  METHODS
  We considered 5 areas where there is conflicting or insufficient evidence: pediatric psoriasis, risk of infection in patients being treated with biologics, psoriasis in difficult locations, biologic drug survival, and impact of disease on quality of life. Following discussion of the issues by an expert panel of dermatologists specialized in the management of psoriasis, participants answered a questionnaire survey according to the Delphi method.
  
  
  RESULTS
  Consensus was reached on 66 (70.9%) of the 93 items analyzed; the experts agreed with 49 statements and disagreed with 17. It was agreed that body mass index, metabolic comorbidities, and quality of life should be monitored in children with psoriasis. The experts also agreed that the most appropriate systemic treatment for this age group was methotrexate, while the most appropriate biologic treatment was etanercept. Although it was recognized that the available evidence was inconsistent and difficult to extrapolate, the panel agreed that biologic drug survival could be increased by flexible, individualized dosing regimens, continuous treatment, and combination therapies. Finally, consensus was reached on using the Dermatology Quality of Life Index to assess treatment effectiveness and aid decision-making in clinical practice.
  
  
  CONCLUSIONS
  The structured opinion of experts guides decision-making regarding aspects of clinical practice for which there is incomplete or conflicting information.
authors.affiliation: Servei de Dermatologia, Hospital Universitari GermansTrias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, España. Electronic address: jmcarrascosac@hotmail.com.
authors.forename: J M
authors.initials: JM
authors.lastname: Carrascosa
authors.affiliation: Servicio de Dermatología, Hospital de Jaén, Jaén, España.
authors.forename: M
authors.initials: M
authors.lastname: Galán
authors.affiliation: Servicio de Dermatología, Hospital Universitario La Paz, Madrid, España.
authors.forename: R
authors.initials: R
authors.lastname: de Lucas
authors.affiliation: Servicio de Dermatología, Hospital General de Valencia, Valencia, España.
authors.forename: A
authors.initials: A
authors.lastname: Pérez-Ferriols
authors.affiliation: Servicio de Dermatología, Hospital Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Barcelona, España.
authors.forename: M
authors.initials: M
authors.lastname: Ribera
authors.affiliation: Servicio de Dermatología, Hospital Universitario de Navarra, Pamplona, España.
authors.forename: I
authors.initials: I
authors.lastname: Yanguas
mesh_terms: D000328:Adult; D000911:Antibodies, Monoclonal / Q000009:adverse effects / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000009:adverse effects / Q000627:therapeutic use; D001691:Biological Therapy / Q000009:adverse effects; D002648:Child; D002986:Clinical Trials as Topic; D003131:Combined Modality Therapy; D003697:Delphi Technique; D019468:Disease Management; D004198:Disease Susceptibility; D000068800:Etanercept / Q000009:adverse effects / Q000627:therapeutic use; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use; D007239:Infections / Q000209:etiology; D008727:Methotrexate / Q000009:adverse effects / Q000627:therapeutic use; D011565:Psoriasis / Q000188:drug therapy / Q000628:therapy*; D011788:Quality of Life; D011795:Surveys and Questionnaires; D014467:Ultraviolet Therapy
chemical_list: D000911:Antibodies, Monoclonal; D018501:Antirheumatic Agents; D007166:Immunosuppressive Agents; D000068800:Etanercept; D008727:Methotrexate
keywords: Biologics; Biológicos; Calidad de vida; Palmoplantar psoriasis; Pediatric psoriasis; Psoriasis; Psoriasis Palmoplantar; Psoriasis Pediátrica; Psoriasis del Cuero cabelludo; Psoriasis of the scalp; Quality of life