The NICE ( National Institute for Health and Clinical Excellence ) has developed guidance on the use within the NHS in England and Wales of Etanercept ( Enbrel ) and Efalizumab ( Raptiva ) for the treatment of psoriasis, and Etanercept and Infliximab ( Remicade ) for the treatment of psoriatic arthritis.

Psoriasis is a skin disease, affecting about 2% of the population, in which the normal processes of skin cell replacement are speeded up. Under normal circumstances new skin cells rise to the surface of the skin, and the dead ones at the surface drop off. In people with psoriasis this happens so quickly that the new skin cells get to the surface before the old ones have died and dropped off. This causes raised red patches of skin covered with silvery scales which are known as ‘plaques’. Psoriasis does get worse over time, but it can be unpredictable with symptoms ranging from mild to severe.
There is no cure for psoriasis but there are a wide range of topical and systemic treatments that can potentially manage the condition.
Most treatments, however, only reduce the severity rather than stop the episodes, and the psoriasis therefore has to be treated continually and on a long-term basis. The burden for the person with psoriasis can be considerable as many of the preparations used to treat the condition have a strong smell, are messy and require application two or three times a day.

Psoriatic arthritis is an inflammatory arthritis closely associated with psoriasis. An estimated 5-7% of all people with psoriasis, and approximately 40% of those with extensive skin disease, have psoriatic arthritis. Like psoriasis, psoriatic arthritis is a chronic progressive condition whose course may be erratic, with flare-ups and periods of remission.
Treatments for psoriatic arthritis include non-steroidal anti-inflammatory drugs ( NSAIDS ), physiotherapy, corticosteroid injections, disease-modifying anti-rheumatic drugs ( DMARDs ) and topical therapies. However, there are few drugs that are specifically licensed to treat psoriatic arthritis, and this, combined with the fact that the condition is managed by a number of specialties, has resulted in widespread variations in practice.


The guidance on the use of Etanercept and Efalizumab for the treatment of psoriasis recommends:

- The use of Etanercept, within its licensed indications, as an option for the treatment of adults with severe plaque psoriasis when: other treatments haven’t worked ( for example, Ciclosporin, Methotrexate and ultraviolet radiation ) or, the person is intolerant to, or has a contraindication to, these treatments.

- Treatment with Etanercept should be discontinued if the person’s psoriasis has not shown a measured response after 12 weeks. Further treatment cycles are not recommended in these patients.

- Efalizumab should be offered as an option for treating adults with severe plaque psoriasis if: treatment with Etanercept has not worked or the person is intolerant of, or has contraindications to, treatment with Etanercept.

- Treatment with Efalizumab should be discontinued if the person’s psoriasis has not shown a measured response after 12 weeks.

An measured response is defined as either:

- a 75% reduction in the PASI score from when treatment started ( PASI 75 ) or

- a 50% reduction in the PASI score ( PASI 50 ) and a five-point reduction in DLQI 2 from when treatment started.


The guidance on the use of Etanercept and Infliximab for the treatment of psoriatic arthritis recommends:

- Etanercept should be offered as an option for the treatment of adults with severe active psoriatic arthritis when: the person has peripheral arthritis with three or more tender joints and three or more swollen joints and other DMARDs, administered either individually or in combination, have not worked.

- Treatment with Etanercept should be discontinued if the person’s psoriatic arthritis has not shown a measured response after 12 weeks.

- Infliximab should be offered as an option for treatment for treating adults with severe active psoriatic arthritis if: treatment with Etanercept has not worked or, the person is intolerant of, or has contraindications to, treatment with Etanercept.

- Treatment with Infliximab should be discontinued if the person’s psoriatic arthritis has not shown a measured response after 12 weeks.

A measured response is defined as an improvement in at least two of the four Psoriatic Arthritis Response Criteria ( PsARC ), one of which has to be joint tenderness or swelling score, with no worsening in any of the four criteria.

Source: NICE, 2006


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