QHow do I manage patients on psoriasis biologics who are having surgery?

Nicholas Brownstone, MD

Nicholas Brownstone, MD

Dermatology Resident
Temple University Hospital
Philadelphia, PA

Unfortunately, there are no large double-blind, randomized placebo-controlled studies on this topic and large-scale, evidence-based studies are lacking. The clinician must balance the risk of a psoriasis flare during surgery with the theoretical risk of infection and delayed wound healing for a patient on a psoriasis biologic therapy. To help guide clinicians on this issue, The American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) have developed an expert consensus on the perioperative management of patients on psoriasis biologics. The AAD/NPF guidelines stratify surgical procedures into low-, moderate and high risk. Low-risk surgery includes: endoscopic procedures, dermatological procedures, breast biopsies/excisions, ophthalmological procedures, and orthopedic surgery/joint replacements. Moderate-risk surgery includes: urological surgery, thoracic or abdominal surgery, and head/neck surgery. High-risk surgery includes: emergency surgery, complicated thoracic/abdominal/GU procedures, and surgical procedures on infected areas.

It is the expert opinion of the AAD/NPF task force that all biologics can be continued through low-risk procedures. If the patient is undergoing a moderate- or high-risk procedure, a discussion with the surgical team is necessary, and stopping the medication can be considered on a case-by-case basis given the severity of the patient’s psoriasis, individual risk factors, and comorbidities. A recent study in the Journal of the American Academy of Dermatology found that there was no increased risk of postoperative skin and soft tissue infection with certain biologic agents (adalimumab, etanercept, infliximab, and ustekinumab).


  1. Nguyen ED, Gabel CK, Kroshinsky D. Assessing the incidence of skin and soft tissue infection in patients on biologics. J Am Acad Dermatol. 2021;85(3):604-610. doi:10.1016/j.jaad.2020.03.128
  2. Menter A, Strober BE, Kaplan DH, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. J Am Acad Dermatol. 2019;80(4):1029-1072. doi:10.1016/j.jaad.2018.11.057