"#$%&'(&)*+",-+.

/0$12)3456(7*6'8#
(Psoriasis)

72
Clinical Practice Guideline for Psoriasis
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73
3$&Y#a&
&'()*+,-.+/01 (psoriasis) +:;1&'(<=>?=,@'AB,+)C+'DEA'B/FA/G0HI1B/ &.J?=KB,LM*)N@(BO(DA GD>1
G0HI1B/?=A@,@'P./ FQJI1@ A@R?=A@,@'(B1 &'()*+,-.+/01?=(H@?)B?SB1TU,BC'*CCVW@/X Y1'W@/,@JIK@J
'*CC +ZW1?=(H@?)B?SB1TU,BC&'(F[AAB,+)C)*+,-.+/01 (psoriatic arthritis), inflammatory bowel disease,
SB1TQ,''?PK*)0>/PH.K[A?,-+:;1:iRRBJ)W/+)'0?YI[+,0.&'(PK*,'*VQ[1YI[?=A@,@'j.[
#81&Y
&'()*+,-.+/01 +:;1&'(+'DEA'B/ +,0.R@,(H@?G0.:,V0FA/'*CCkl?0(Q[?,B1&.J?= <N@YI[?=,@'AB,+)C
'WH?,BC?=,@'PCW/VBHFA/+mKG0HI1B/+'-HG0.:,V0
)5Z&*$8%1&
&'()*+,-.+/01SCj.[:'*?@M'[AJK* 1-2 FA/:'*Z@,'<BE/I?. SCj.[<Q,+ZDEAZ@V0 ABV'@,@'+,0.&'(
+<W@,B1<BE/+SpZ@JPK*+SpIO0/ R@,,@'pq,L@Y1Gl[:rHJ&'()*+,-.+/01RN@1H1 2,400 '@J SC(H@?t=>Y1,@'+,0.
&'(?= 2 ZWH/(DAZWH/A@JQ1[AJ (22.5 :w) PK*A@JQ?@, (55 :w)(1, 2) Gl[:rHJ&'()*+,-.+/01<=>P)./A@,@'FA/&'(VBE/PVW
A@JQ1[AJR*SC?=(H@?'Q1P'/FA/&'(?@,,HW@,KQW?Gl[:rHJA@JQ?@,PK*SC?=&A,@)<=>(1Y1('AC('BHR*+:;1&'(
)*+,-.+/01.[HJ
4&6PVN
JB/j?W<'@C)@+IVQ<=>P1WZB. R@,IKB,x@1Y1:iRRQCB1<'@CHW@1W@R*+,0.R@,IK@J:iRRBJ'WH?,B1 j.[P,W
SB1TQ,''? '*CCkl?0(Q[?,B1PK*:iRRBJ,'*VQ[1k@J1A,
/)56M%b^'2)3456(7*6'8#
Plaque psoriasis
+:;1KB,LM*GD>1G0HI1B/<=>SCCWAJ<=>)Q. :'*?@M'[AJK* 80-90 FA/Gl[:rHJ<BE/I?. 'AJ&'(?=KB,LM*
+:;1GD>1P./I1@ FAC+FVZB. )*+,-.I1@ FQJ?@, F1@.VBE/PVW 1 +m-1V0+?V'FqE1j: SCCWAJC'0+HMI1B/p='L*
KN@VBH ,[1PK*PF1F@<BE/)A/F[@/ &.J+{S@*C'0+HM extensor +ZW1 F[ApA, +FW@ +:;1V[1 :'*?@M'[AJK* 80 FA/
Gl[:rHJ?=(H@?'Q1P'/1[AJtq/:@1,K@/ +S=J/'[AJK* 20 +<W@1BE1<=>?=(H@?'Q1P'/:@1,K@/tq/?@, (DA?='AJ&'(
<B>H'W@/,@J?@,,HW@'[AJK* 10 FA/SDE1<=>G0H'W@/,@J<BE/I?. I'DA?='AJ&'(Y1VN@PI1W/<=>)N@(BO +ZW1 ?DA +<[@
I1[@ PK*AHBJH*+Sp +:;1V[1
Guttate psoriasis
+:;1)*+,-.+/01<=>?='AJ&'(+:;1VQW?P./ ?=FQJ (fine scale) VQW??=F1@.+K-,j?W+,01 1 +m-1V0+?V' C'0+HM
KN@VBH V[1PF1 V[1F@ SCj.[1[AJ,HW@'[AJK* 10-20 FA/Gl[:rHJ<BE/I?. Gl[:rHJ?B,?=A@JQ1[AJ,HW@ 30 :w PK*A@R?=
:'*HBV0,@'V0.+ZDEA<@/+.01I@JYR)WH1C1 &.J+{S@* group A beta-hemolytic streptococci 1N@?@,WA1
:'*?@M 2-3 )B:.@IU A@R+:;1A@,@'('BE/P',FA/Gl[:rHJ I'DA+:;1,@',N@+'0CY1Gl[:rHJ plaque psoriasis <=>?=
A@,@'?@1@1,-j.[

74
Pustular psoriasis
'AJ&'(?=KB,LM*+:;1VQW?I1A/ PCW/j.[+:;1
- Generalized pustular I'DA acute generalized variant (von Zumbusch variant) +:;1&'()*+,-.+/01Z10.
'Q1P'/<=>?=VQW?I1A/ ,'*R@J<B>HG0HI1B/<=>?=,@'AB,+)CP./
- Localized pustular variant ?B,SCC'0+HM Ür@?DA Ür@+<[@ &.JA@R?= plaque psoriasis 'WH?.[HJj.[
Erythrodermic psoriasis
+:;1GD>1'AJ&'(<=>?=KB,LM*P./+,DAC<B>HSDE1<=>G0H<BE/I?.FA/'W@/,@J ?=:'0?@MFQJ<=>PV,VW@/,B1j:
A@RSBá1@R@, plaque psoriasis I'DA+,0.j.[<B1<= 1A,R@,1=EA@RSC jF[)l/ AWA1+SK=J I1@H)B>1 PK*,@'
)lO+)=J1EN@PK*&:'V=1Y1'W@/,@J (dehydration and hypoalbuminemia) 'WH?.[HJj.[
Inverse psoriasis
(DA)*+,-.+/01<=>GD>1'AJ&'(Y1C'0+HMmA,SBCFA/'W@/,@J j.[P,W 'B,P'[ C'0+HMAHBJH*+Sp F@I1=C PK*
YV['@H1? +:;1V[1 +1D>A/R@,C'0+HM+IKW@1=E?=(H@?ZQW?ZDE1AJlWPK[H Rq/SC?=FQJI'DA)*+,-.j?W?@,
Psoriatic nails
(H@?G0.:,V0FA/+K-C)@?@'tSC'WH?.[HJY1&'()*+,-.+/01<Q,:'*+k< SC<=>10EH?DAj.['[AJK* 50
Y1FM*<=>10EH+<[@SCj.['[AJK* 35 FA/Gl[:rHJ<BE/I?. (H@?G0.:,V0j.[P,W pitting, onycholysis, subungual
hyperkeratosis PK* oil-drop sign )N@I'BC,KQW?F[AAB,+)C)*+,-.+/01 (psoriatic arthritis) ?B,?=(H@?G0.:,V0<=>
+K-C'WH?.[HJj.[tq/'[AJK* 90
Psoriatic arthritis
F[AAB,+)C)*+,-.+/01 (DA,@'AB,+)CFA/F[A<=>+,0.R@,&'()*+,-.+/01 mq>/?=(H@?)N@(BO+1D>A/R@,,@'
AB,+)CFA/F[AY1&'()*+,-.+/01?B,<N@YI[+,0.,@'S0,@'G0.'l:j.[CWAJ AQCBV0,@'PV,VW@/,B1?@,V@?,KQW?Gl[:rHJ<=>
<N@,@'pq,L@F[A?lKSCj.['[AJK* 1-40 FA/Gl[:rHJ&'()*+,-.+/01

(&)$8#8XkR1 A@pBJ:'*HBV0PK*,@'V'HR'W@/,@J+:;1IKB,
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2.A@RR*?=I'DAj?W?=A@,@'(B1
3.C@/'@J?=:'*HBV0('AC('BH
4.GD>1A@R,N@ +'0C j.[k@JIKB/k@H*V0.+ZDEA (H@?+('=J . I'DAIKB/j.['BCJ@C@/Z10. +ZW1 lithium,
antimalaria, beta-blocker, NSAIDS PK* alcohol

75
 (&)V)$X)l&'(&1
-8$P#R' ?=GD>1I1@)=P./ FACZB.+R1(KQ?.[HJFQJmq>/SCj.[IK@JKB,LM* A@<0 FQJI1@F@H(K[@J)=
+/01 mq>/)@?@'tFl.AA,j.[/W@J PK*+?D>AFl.FQJAA,I?.R*?=RQ.+KDA.AA,C1'AJGD>1 (Auspitzés
sign) FQJ F@HK*+A=J . FQJ )=+IKDA/GD>1)*+,-.+/01A@R+,0.C1'AJPGKtKA,I'DA'AJPGKGW@ VB.
(Koebner phenomenon)
6,7 Z SC?= I KQ ? (pitting) +K- C 'W A 1(onycholysis) :K@J+K- C I1@?= FQ J YV[ + K- C (subungual
hyperkeratosis) I'DA RQ.)=1EN@V@KYV[+K-C(oil spot)
b.^ ?=,@'AB,+)CFA/+A-1PK*F[Amq>/A@R+:;1j.[<BE/F[AYIOW F[A+K-, +:;1F[A+.=JH I'DA IK@JF[A
&.J)WH1YIOW,@'AB,+)C<=> distal interphalangeal joint tDA+:;1KB,LM*RN@+S@*FA/&'(F[AAB,+)C
)*+,-.+/01PK*A@RR*?=F[AS0,@'V@?IKB/,@'AB,+)C+'DEA'B/

(&)/)56Y8#3$&Y)N#")'b^'2)3
• The Psoriasis Area and Severity Index (PASI) +:;1,@':'*+?01(H@?'Q1P'/FA/GD>1R@,
body surface area involvement, erythema, induration and scaling FA/GD>1Y1)WH1VW@/XFA/
'W@/,@J &.J<B>Hj:(H':'*+?01 PASI ,WA1,@''B,L@ '*IHW@/,@''B,L@ PK*)0E1)Q.,@''B,L@
('@JK*+A=J.,@'(N@1HMI@PASI score .B/k@(G1H,)
• Body surface area (BSA) +:;1,@':'*+?01(H@?'Q1P'/FA/GD>1&.J.lSDE1<=>FA/G0HI1B/<=>+:;1
&'( H0T=,@'HB.&.JYZ[Ür@?DAFA/Gl[:rHJ+:;1+('D>A/HB.,N@I1.YI[ 1 Ür@?DAFA/Gl[:rHJ+:;1'[AJK* 1
FA/SDE1<=>G0HI1B/<BE/I?.
• Dermatology Life Quality Index (DLQI) +:;1,@':'*+?01(QMk@SZ=H0VFA/Gl[:rHJ&'(
G0HI1B/(2) ('@JK*+A=J..B/k@(G1H,)

"Zl'3$&Y)N#")'b^'2)3456(7*6'8#*R'#]v
• Mild psoriasis I?@Jtq/ )*+,-.+/01(H@?'Q1P'/1[AJ &.J.lR@,SDE1<=>'AJ&'( < 10% body
surface area (BSA), PASI<10, DLQI <10
• Moderate to severe psoriasis I?@Jtq/ )*+,-.+/01(H@?'Q1P'/:@1,K@/tq/?@,&.J.lR@,
SDE1<=>'AJ&'( >10% BSA, PASI > 10, DLQI> 10
• -xy#456(7*6'8#%]yzZP#.& Yx^",56%.& 'H?<BE/AHBJH*+Sp P?[SDE1<=>FA/'AJ&'(R*1[AJ,HW@ 10%
PVWI@,)W/GKVWA(QMk@SZ=H0VFA/Gl[:rHJR*RB.AJlWY1,KQW? moderate to severe psoriasis

76
(&)V)$X%&'P.^'/{8ZRV8(&)
(&)V)$X%&'K1&W8$8%1& SJ@T0)k@SFA/GD>1)*+,-.+/01R*?=KB,LM*+{S@* PVWj?WRN@+:;1V[A/<N@,@'
V'HR<Q,'@J A@R<N@+SD>AZWHJY1,@'H010R{BJPJ,&'( +SD>AJD1JB1,@'H010R{BJPK*ZWHJH010R{BJ&'(Y1,'M=
<=>?=:iOI@
(&)V)$XVl^`/#]v6,x^(%a&6kK&5-+./0$1%]yY]^&(&) P)x^b.^Zl'U]v
1.J[A?)=,'B?PK*+S@*+ZDEAPC(<=+'=J t[@?=VQW?I1A/
2.t[@?=A@,@'F[AAB,+)C(H')W/V'HR<@/'B/)=PK*V'HRI@ rheumatoid factor +SD>APJ,&'(
rheumatoid arthritis
3.Y1'@J<=>?=A@,@''Q1P'/ +{=JCSKB1I'DA?=:iRRBJ+)=>J/ (H'+R@* anti HIV antibody

(&)V)$XP&2)3%]y6(8*)l$Y(RZ2)3456(7*6'8# (Medical comorbidities associated with psoriasis )

Metabolic syndrome: ,KQW?&'(<=>:'*,AC.[HJ obesity, diabetes mellitus, dyslipidemia
(hypertriglyceridemia and low high-density lipoprotein) PK* hypertension SCHW@Gl[:rHJ&'()*+,-.+/01?=
AQCBV0,@',@'+,0. metabolic syndrome ?@,,HW@Gl[:rHJ<=>j?W+:;1&'()*+,-.+/01PK*1N@j:)lW cardiovascular
disease VWA?@(3-8).B/1BE1Rq/(H'V'HR'W@/,@J HB.(H@?.B1 ZB/> 1EN@I1B, HB.)WH1)l/ +SD>A:'*+?01 BMI PK*+R@*
+KDA. j.[P,W fasting blood sugar, lipid profiles +SD>AI@&'(Y1,KQW? metabolic syndrome Y1Gl[:rHJ&'()*+,-.
+/01
Autoimmune diseases: F[A?lKY1VW@/:'*+<p SCAQCBV0,@',@'+,0.&'( Crohnés disease PK*
ulcerative colitis Y1Gl[:rHJ&'()*+,-.+/01 3.8-7.5 +<W@+?D>A+:'=JC+<=JC,BC:'*Z@,'<B>Hj:(9) 1A,R@,1=E?=
,@'pq,L@SC,@'+,0.&'( multiple sclerosis )l/ FqE1Y1('AC('BH<=>+:;1&'()*+,-.+/01 )1BC)1Q1HW@ ?=
(H@?)B?SB1TU<@/SB1TQ,''?'*IHW@/&'(.B/,KW@H(10)
Lymphoma ,@'pq,L@Y1:'*+<pAB/,õL SCAQCBV0,@',@'+,0.&'( lymphoma Y1Gl[:rHJ&'()*+,-.
+/01)l/FqE1 3 +<W@+?D>A+:'=JC+<=JC,BC,KQW?(HC(Q?<=>?=A@JQ PK*+SpY,K[+(=J/,B1(11)

(&))R(_&2)3456(7*6'8#
+1D>A/R@,&'()*+,-.+/01+:;1&'(+'DEA'B/<=>JB/j?W<'@C)@+IVQZB.+R1 ,@''B,L@Rq/+:;1,@'G)?G)@1H0T=,@'<=>
IK@,IK@J (combination therapy) PS<JUGl['B,L@RN@+:;1V[A/<'@CF[A.=F[A+)=J PK*:'*)0<T0k@SFA/PVWK*H0T=
&.J+KD A,YZ[ Y 1PVWK *,'M= PK*?= , @'I?Q1+H=J 1H0T=, @''B, L@ (rotational therapy) +SD>AIK=, +K=>J /PK*K.
GKF[@/+(=J/R@,,@'YZ[J@PVWK*:'*+k<
1. ,@''B,L@V@??@V'x@1 (Standard treatment)
1.1. J@<@k@J1A,
1.2. J@'BC:'*<@1

77
 1.3. ,@'YZ[P)/P..+<=J? (Phototherapy, Photochemotherapy)
1.4. J@{=.,KQW?Z=Hk@S
2. ,@''B,L@:'*(BC:'*(A/ (Supportive treatment)
3. ,@':'*(BC:'*(A/<@/R0VYR (Psychotherapy)

(&)zP.3$&Y)+.6(]y1$(RZ2)3"(l-+./0$1",5Q&V8 (Education)
- &'()*+,- .+/01+:;1 &'(+'DEA'B / <=>?=A@,@'+.W1<@/G0HI1B/ AB, +)C j?W) @?@'t'B, L@I@JF@.j.[ P VW
)@?@'t(HC(Q?&'(j.[ Y1C@/,'M=A@R?=GD>1VKA.Z=H0V PK*&'(A@R?=,@',N@+'0C+:;1ZWH/X j.[
- &'()*+,-.+/01+:;1&'(j?WV0.VWA
- (H'IK=, +K=>J/:iRRBJ ,'*VQ[1YI[&'(,N@+'0C +ZW1 ,@'.D>?+IK[@ ,@')lC CQI'=> ,@'P,*+,@ PK*'C,H1
G0HI1B/Y1KB,LM*VW@/X G0HjI?[P./R@,P)/P.. PK* (H@?+('=J. (stress) +:;1V[1
- ,@'V0.+ZDEA<N@YI[&'(,N@+'0CFqE1j.[
- J@C@/Z10. +ZW1 J@V[@1?@K@+'=J J@K.(H@?.B1&KI0V,KQW? beta-blocker, J@ lithium )@?@'t,'*VQ[1
YI[&'(,N@+'0Cj.[
- ?=H0T=,@''B,L@&'(IK@JH0T= mq>/PVWK*H0T=?=F[A.= GKF[@/+(=J/ :'*)0<T0k@S PK*F[A(H''*HB/PV,VW@/,B1
(&))R(_&*.$11&%& (Topical therapy)
J@<@<=>?=YZ[Y1:'*+<pj<J:iRRQCB1 j.[P,W
1. Corticosteroids
2. Tar
3. Dithranol (Anthralin)
4. Calcipotriol
5. Calcineurin inhibitor
6. Salicylic acid

1&%&(,NlY46V^)^1*L (Topical steroids)

(,`((&)^^(~%W8•
- K.,@'AB,+)C PK*K.,@'PCW/VBHFA/+mKG0HI1B/ &.JRBC,BC glucocorticoid receptors
$8W]zU.
- J@<@,KQW?)+VA'AJ.U ?=IK@J'*.BC(H@?P'/FA/,@'AA,õ<T0ùYI[+KDA,YZ[ ,@'+KDA,YZ[J@Z10.Y.1BE1
(H'S0R@'M@R@,VN@PI1W/FA/'AJ&'( J@<=>?=õ<T0ùAWA1R*j.[GK,@''B,L@1[AJ,HW@Z10.<=>?=õ<T0ùP'/
,HW@ PVWJ@<=>?=õ<T0ùP'/R*YZ[j.[C@/C'0+HMFA/'W@/,@J PK*(H'YZ[Y1ZWH/)BE1X+<W@1BE1
- J@<=>?=õ<T0ùAWA1A@R<@HB1K* 1-2 ('BE/<Q,HB1

78
 - J@<=>?=õ<T0ùP'/(H'<@HB1K* 2 ('BE/VWA+1D>A/,B1j?W+,01 2 )B:.@IU IKB/R@,1BE1A@R<@HB1+H[1HB1 I'DA
)B:.@IUK* 1-2 ('BE/ +SD>A(HC(Q?&'(
/)548%W8M&K
+?D>A'B,L@PCC monotherapy J@<@'*.BC(H@?P'/:@1,K@/R*j.[:'*)0<T0k@S,@''B,L@.=<=>)Q.
)N@I'BCJ@<@<=?> =õ<T0ùP'/R*?=:'*)0<T0k@S.=Y1ZWH/ 2 )B:.@IUP',FA/,@''B,L@(12, 13) ((QMk@SIKB,x@1'*.BC
1 '*.BC(N@P1*1N@'*.BC A)
-,b.&'63]1'",5b.^3$))5$R'
- G0HI1B/C@/K/
- +,0.'AJPV,FA/G0HI1B/ (Striae) mq>/V[A/'*HB/+:;1AJW@/J0>/C'0+HM'B,P'[ F@I1=C PK*mA,+'[1 VW@/X
- J@tl,.l.mq?+F[@)lW,'*P)+KDA.+,0.,@',.,@'<N@/@1FA/VWA?I?H,jV I@,YZ[+:;1C'0+HM,H[@/VWA+1D>A/
1@1,HW@ 2 )B:.@IU
- ,@'YZ[J@V0.VWA,B1+:;1+HK@1@1R*<N@YI[:'*)0<T0k@SFA/J@K.K/ (Tachyphylaxis)(14)
-
,@'YZ[J@ topical steroid class I <@VWA+1D>A/,B1j?W(H'<@V0.VWA,B11@1+,01 2-4 )B:.@IU PK*j?W(H'YZ[
:'0?@M+,01 50 ,'B?VWA)B:.@IU(15)

#va&YR#*8# (Tars) ((QMk@SIKB,x@1'*.BC 2 '*.BC(N@P1*1N@'*.BC B)

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- K.A@,@'AB,+)C
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- <@.[HJ Tar cream I'DA ointment C1GD>1 mq/> V[A/'*HB/,@''*(@J+(DA/C'0+HMF[ASBCPK* C'0+HMAHBJH*
+Sp (genital area)
- I1B/p='L* )'*.[HJ Tar shampoo
YZ[1EN@?B1.01'WH?,BC,@''B,L@AD>1
- YZ['WH?,BCJ@<@(A'UV0&()+V=J'AJ.U
- PZW tar bath 15-30 1@<=V@?.[HJ,@'{@J UVB I'DAA@CP..
- ,@''B,L@PCC Goeckerman (DA YZ[1EN@?B1.01<@<BE/VBH <0E/jH[:'*?@M 8-12 ZB>H&?/ PK[HK[@/J@AA,
V@?.[HJ,@'{@J UVB
/)548%W8M&K
YI[GK,@''B,L@.=,HW@+?D>A+:'=JC+<=JC,BC placebo(16)

79
-,b.&'63]1'",5b.^3$))5$R'
- 'lFQ?F1AB,+)C (folliculitis)
- G0HI1B/'*(@J+(DA/ (irritant contact dermatitis)
- G0HI1B/AB,+)CR@,,@'PS[ (allergic contact dermatitis)
- +:'A*+:ü†A1+)DEAG[@ PK*?=,K0>1+I?-1
- 1EN@?B1.01 A@R+:;1)@',WA?*+'-/ (H'YZ[.[HJ(H@?'*?B.'*HB/+?D>AYZ['WH?,BC,@''B,L@GD>1 mq>/?=GKVWA
?*+'-/ +ZW1 UVB, PUVA

Anthralin (Dithranol) ((QMk@SIKB,x@1'*.BC 3 '*.BC(N@P1*1N@'*.BC C)

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- ,.,@'PCW/VBHFA/+mKKUZBE1I1B/,N@S'[@
$8W]zU.
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+F[?F[1FqE1j.[+'D>AJX PK[H+Z-.AA,.[HJ1EN@?B1?*,A,t[@YZ[Y1'l:PCCF=EGqE/ I@,YZ[J@Y1'l:('=?)@?@'t
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,WA11A1
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- Etanercept (Enbrel™)
- Infliximab (Remicade™)
- Adalimumab (Humira™) :iRRQCB1 (2552) JB/j?W?R= N@I1W@JY1:'*+<pj<J
2) ?=GK&.JV'/VWA T cells (Targeting pathogenic T cells)
- Efalizumab (Raptiva™) :iRRQCB1 (2552) I[@?RN@I1W@JY1<H=:JQ&': PK*)I'BxA+?'0,@
- Alefacept (Amevive™) :iRRQCB1 (2552) JB/j?W?=RN@I1W@JY1:'*+<pj<J

(&)zU.1&(,NlY Anti-Tumor Necrosis Factor α (Anti-TNF-α) ((QMk@SIKB,x@1'*.BC 1, (N@P1*1N@'*.BC

A(34, 35)

Etanercept (Enbrel™)
recombinant human TNF-α receptor (p75) protein
,Kj,,@'AA,õ<T0ù

88
 RBC,BC Fc portion FA/ IgG1 <N@YI[)@?@'tRBCj.[,BC<BE/ soluble PK* membrane-bound TNF-α
F[ACW/Z=E
- Refractory moderate to severe psoriasis
- Refractory moderate to severe psoriatic arthritis
H0T=YZ[
- Gl[YIOW : 50 ?,. {=.YV[ZBE1G0HI1B/ )B:.@IUK* 1-2 ('BE/ V0.VWA,B1+:;1+HK@ 3 +.DA1 IKB/R@,1BE1 50 ?,. {=.
YV[ZBE1G0HI1B/ )B:.@IUK* 1 ('BE/
- +.-, : 0.8 ?,.VWA1EN@I1B,VBH 1 ,,.(j?W+,01 50 ?,.) VWA('BE/
GKF[@/+(=J/
- ,@'AB,+)CC'0+HM<=>{=.J@ (H@?'Q1P'/1[AJtq/:@1,K@/ SCj.[tq/'[AJK* 37 &.J+{S@*Y1,@'{=.J@+.DA1
P', 1@1 3-5 HB1 j?WRN@+:;1V[A/IJQ.J@+SD>A'B,L@GKF[@/+(=J/1=E
F[A(H'(N@1q/
- :'*)0<T0k@S,@''B,L@)B?SB1TU,BC:'0?@MJ@<=>YZ[ (Dose related response)
- j?WSC,@',KBC+:;1mEN@Y1<B1<= (rebound) IKB/IJQ.YZ[J@ PVWSCP1H&1[?:'*)0<T0k@SK.K/V@?'*J*+HK@
<=>YZ[J@ A@R+1D>A/R@,,@'?=kl?0VWAV[@1 (antibody) +,0.FqE1j.[
- j?W(H'YZ[Y1Gl[<=>PS[ latex +1D>A/R@,+F-?<=>YZ[{=.J@?= latex +:;1)WH1G)?
,KQW?J@ Pregnancy category B

Infliximab (Remicade™)
Chimeric monoclonal antibody )'[@/R@, murine (variable region) PK* human DNA (IgG1-α
constant region)
,Kj,,@'AA,õ<T0ù
RBC,BC<BE/ soluble PK* transmembrane TNF-α molecules
F[ACW/Z=E
- Severe psoriasis
- Generalized pustular psoriasis
- Moderate to severe psoriatic arthritis
H0T=YZ[
- 3-5 ?,. VWA1EN@I1B,VBH (,,.) VWA('BE/ {=.+F[@+)[1+KDA.Z[@X Y1 2 ZB>H&?/<=>)B:.@IU<=> 0, 2, 6 IKB/R@,1BE1 <Q,
6-8 )B:.@IU
'*J*+HK@Y1,@'YZ[
- j?W?=,N@I1.'*J*+HK@<=>P1W1A1

89
GKF[@/+(=J/
- ,@''*(@J+(DA/R@,,@'{=.J@+F[@+)[1+KDA. )B?SB1TU,BC,@'+,0. human antichimeric antibodies mq>/)@?@'t
RB.,@'&.J,@'K.(H@?+'-H,@'{=.J@ I'DAIJQ.YI[J@
- Serum sickness
F[A(H'(N@1q/
- YI[,@'VAC)1A/VWA,@''B,L@+'-H SCP1H&1[?:'*)0<T0k@SK.K/V@?'*J*+HK@<=>YZ[
-
,@'YZ['WH?,BC methotrexate :'0?@MV>N@ A@RZWHJK.,@')'[@/kl?0VWAV[@1 (antibody) VWAJ@1=Ej.[(36)
,KQW?J@ Pregnancy category B
b.^P.&Yb^'(&)zU.1&(,NlY Anti-TNF-α
Absolute contraindications
- Gl[:rHJ<=>?=,@'V0.+ZDEA'Q1P'/ I'DA ,N@KB/?=,@'V0.+ZDEAAJlW
- Gl[:rHJ congestive heart failure class III I'DA IV (New York Heart Association Classification) I'DA
Gl[:rHJ congestive heart failure class I or II <=>?= ejection fraction <50%
- YZ[HB(m=1Z10.?=Z=H0V (live vaccine)

Relative contraindications
- Gl[:rHJ<=>+:;1&'( I'DA ?=O@V0Y,K[Z0. (first-degree relatives) +:;1&'(Y1,KQW? demyelinating disease
+ZW1 multiple sclerosis
- YZ[HB(m=1Z10.<=><N@YI[+ZDEAAWA1,N@KB/K/ (inactive) I'DA recombinant vaccine
b.^3$)3a&#í'
- )@?@'t<N@YI[&'(HBM&'(,N@+'0Cj.[
- )@?@'t<N@YI[&'(jH'B)VBCAB,+)CC=,N@+'0Cj.[

(&)V)$X%&'P.^'/{8ZRV8(&)(l^#6)8yY(&))R(_&*.$11&(,NlY Anti-TNF-α
- PPD (Purified Protein Derivative) ,@'P:KGK tuberculin test .B/k@(G1H,
- CBC
- Liver function test
- Hepatitis profile, HIV
- CXR
(&)V)$XV8*V&Y%&'P.^'/{8ZRV8(&)z#-+./0$1%]y`*.1&(,NlY Anti-TNF-α
- CBC <Q, 3-6 +.DA1

90
 - Liver function test <Q, 3-6 +.DA1
- PPD <Q,:w, CXR <Q,:w
-,b.&'63]1'%]y4a&3RQb^'1&(,NlY Anti-TNF-α (<=>?='@J/@1)
- ,@',N@+'0CFA/&'(HBM&'( &'(V0.+ZDEA{HJ&A,@) PK*&'(?*+'-/C@/Z10.j.[
- ,'*VQ[1YI[+,0.Kl:i) (drug induced lupus) <=>j?W?=k@H*<@/jV I'DA k@H*<@/'*CC:'*)@<'WH?.[HJ
mq>/)@?@'tI@Jj.[+?D>AIJQ.,@'YZ[J@ (reversible)
- +mKKU+?-.+KDA.V>N@,HW@:,V0 (cytopenia)
- ,'*VQ[1YI[+,0.&'( multiple sclerosis
- <N@YI[+,0. (new onset) I'DA <N@YI[?=A@,@',N@+'0C (exacerbation) FA/k@H*IBHYRK[?+IKH (Congestive
Heart Failure)
3$&Y/,^*MR1z#(&)zU.1&(,NlY Anti-TNF-α
,@'V0.+ZDEA
- ?=,@',N@+'0CFA/HBM&'( PK*+S0>?AQCBV0,@'MU,@'+,0.HBM&'(1A,:A. (extrapulmonary TB)
PK*HBM&'(Z10.PS'W,'*R@Jj.[ (disseminated TB) &.JSC,@',N@+'0CFA/HBM&'(R@,
etanercept 1[AJ,HW@ infliximab I'DA adalimumab
- +S0>?&A,@),@'V0.+ZDEA &.J+{S@*&'(V0.+ZDEA{HJ&A,@) +ZW1 histoplamosis, listeriosis,
coccidioidomycosis, cryptococcosis, aspergillosis, candidiasis PK* pneumocystis ,@'V'HR
V0.V@?PK*,@':'*+?01Rq/+:;1+'D>A/<=>RN@+:;1 +?D>A?=,@'V0.+ZDEA<=>V[A/j.['BCJ@:¨0Z=H1* (H'
IJQ.,@'YZ[J@,KQW?1=E
- ?=,@',N@+'0CFA/&'(jH'B)VBCAB,+)CC= PK*m= (Hepatitis B and C)
&'(<@/'*CC:'*)@<
- SC,@','*VQ[1YI[+,0.&'( I'DA<N@YI[?=A@,@'?@,FqE1 Y1,KQW?&'( demyelinating disease
&'(IBHYR
- ,@'?=GKVWAGl[:rHJk@H*IBHYRK[?+IKH (congestive heart failure, CHF) JB/+:;1<=>t,+t=J/,B1AJlW
AJW@/j',-.= I[@?YZ[J@,KQW? Anti-TNF-α Y1Gl[:rHJ<=>?=k@H*IBHYRK[?+IKHZ10.'Q1P'/ (CHF
class III or IV) +1D>A/R@,,'*VQ[1YI[+,0. (new onset) I'DA<N@YI[?=A@,@'?@,FqE1j.[
(exacerbation)
,@','*VQ[1YI[+,0.k@H*Kl:i) (drug induced lupus-like syndrome)
- ,@'YZ[J@Y1,KQW? Anti-TNF-α <N@YI[+,0. circulating antinuclear antibodies ?@,FqE1 AJW@/j'
,-V@? k@H*1=E)@?@'t,KBC?@:,V0j.[ (reversible) +?D>AIJQ.,@'YZ[J@ j?WRN@+:;1V[A/V'HR
antinuclear antibodies ,WA1I'DA'*IHW@/,@''B,L@t[@j?W?=A@,@'<=>)/)BJ&'(VBC

91
 - ?=GK<N@YI[ transaminase enzyme +S0>?FqE1 &.J+{S@*R@,J@ infliximab

?*+'-/VWA?1EN@+IKDA/
- ?=<BE/,@'pq,L@<=>SCAQCBV0,@'MU?*+'-/VWA?1EN@+IKDA/+S0>?FqE1 PK*j?WSC(H@?PV,VW@/R@,,KQW?
(HC(Q? Y1,@'YZ[J@,KQW? Anti-TNF-α AJW@/j',-V@? (H'S0R@'M@+:;1S0+pLY1Gl[:rHJ<=>?=
:'*HBV0?*+'-/ &.J+{S@*?*+'-/VWA?1EN@+IKDA/
?*+'-/G0HI1B/Z10. melanoma PK*Z10. non-melanoma
- SC,@''@J/@1,@'+S0>?AQCBV0,@'MU?*+'-/G0HI1B/Y1Gl[:rHJ<=>YZ[J@ Anti-TNF-α )N@I'BC?*+'-/
Z10.AD>1 (solid cancers) ?=<BE/,@'SCAQCBV0,@'MU+S0>?FqE1 PK*j?WPV,VW@/R@,,KQW?(HC(Q?
&'(+KDA.
- ?='@J/@1,@'+,0. aplastic anemia, isolated leucopenia PK* thrombocytopenia R@,,@'YZ[J@
Anti-TNF-α
,@'VAC)1A/<@/'W@/,@JAD>1X
- ?='@J/@1,@'+,0. leukocytoclastic vasculitis Y1,@''B,L@ rheumatoid arthritis

V&)&'%]y 1 4)N/ The strength of recommendation for the treatment of psoriasis using topical, traditional systemic and
biologic therapies(15, 38, 39)
1&/(&))R(_& Level of evidence Strength of recommendation
Topical Therapies
Class I topical corticosteroid 1 A
Class II topical corticosteroid 2 B
Class III/IV topical corticosteroid 1 A
Class V/VI/VII topical corticosteroid 1 A
Coal tar 2 B
Vitamin D analoques 1 A
Anthralin (Dithranol) 3 C
Topical tacrolimus and pimecrolimus 2 B
Topical corticosteroid + salicylic acid 2 B
topical corticosteroid + vitamin D analoque 1 A
Topical tacrolimus + salicylic acid 2 B
Traditional systemic therapies
Methotrexate 2 B

92
Acitretin 2 B
Cyclosporine 2 B
Azathioprine 3 C
Hydroxyurea 3 C
Leflunomide 2 B
Sulfasalazine 2 B
Biologic therapies
Infliximab 1 A
Etanercept 1 A
Adalimumab 1 A
Alefacept 1 A

93
 "-#M+Y8%]y 1 bRv#V^#(&)*+",-+./0$1456(7*6'8#

Psoriasis

No arthritis Arthritis

Limited disease Extended disease Follow the guideline of Thai

(<10% BSA, PASI < 10) (> 10% BSA, PASI >10) Rheumatism Association

UVB/PUVA + Topical Rx Systemic drugs + Topical Rx

Topical/Targeted phototherapy

Lack of efficacy Lack of efficacy

Combination UVB/PUVA and systemic drugs

Lack of efficacy

Biologic drugs*
* J@1=E+:;1J@'@(@PS/ PK*?=GKF[@/+(=J/j.[?@, (H'YZ[&.JGl[+Z=>JHZ@O V@?
+/-UVB/PUVA
IKB,+,MÆU,@'+C0,RW@JJ@FA/,'?CBOZ=,K@/ +/-Systemic drugs
94
 V&)&'%]y 2 "#$%&'(&))R(_&2)3456(7*6'8#%]yKZZl^1

23456789:;<=5;843 Topical Systemic Phototherapy

Tar Steroid Vit D3 Dithranol MTX Retinoid Cyclosporine PUVA UVB/Narrowband UVB
Guttate 1 1 1 2 1 - - 2 1
Plaque
• Limited 1 1 1 1 2 - - - 2
(< 10%BSA, PASI <10)
• Extended 1 1 1 1 1 2 2 1 1
(> 10%BSA, PASI >10)
Scalp psoriasis 1 1 2 2 - - - - -
Nail Psoriasis - 1 2 - - - - - -
Psoriatic arthritis See guideline of Thai Rheumatism Association

1, 2, 3 PY&1îí'3$)6,x^(6/ï#,a&*RZ%]y 1, 2, 3

95
 V&)&'%]y 3 "#$%&'(&))R(_&2)3456(7*6'8#6kK&5(,NlY

U#8*b^'456(7*6'8# Topical Systemic Phototherapy

Tar steroid Vit D3 Dithranol MTX Retinoid Cyclosporine Biologics PUVA UVB/Narrowband UVB
Recalcitrant plaque psoriasis S0R@'M@YI[V@?
(H@?+I-1FA/
Gl[+Z=>JHZ@O

Pustular psoriasis
• Limited - 1 - - 1 1 3 - 2 3
(< 10%BSA, PASI <10)
(local PUVA) -
• Extended - 3 - - 1 1 2 4 3 -
(> 10%BSA, PASI >10)
Psoriasis erythroderma - 3 - - 1 3 1 4 2 3
Psoriasis in pregnancy 2 1 1 1 - - - - - 1
Psoriasis in HIV or 1 1 1 1 - 1 - - - 2
Immunocompromised host S0R@'M@YI[V@?(H@?+I-1FA/
Gl[+Z=>JHZ@O

PY&16PVN (&))R(_&V&YV&)&'#]vzU.()O](&))R(_&U#8* monotherapy, z#-+./0$1Z&')&1 (&))R(_&*.$1 combination therapy X5`*.-,(&))R(_&*]($l&

96
V&)&'%]y 4 4)N/(&))R(_&*.$1)R'4]*.$1(&)k&1"4' (Phototherapy and photochemotherapy)(27)
Narrowband UVB Broadband UVB Psoralen&UVA Excimer laser
(NB-UVB 310- (BB-UVB 290- (PUVA)(28-31) (308nm)(32)
313nm) 320nm)
Dosing :'*+?01 MED ,WA1 :'*+?01MED ,WA1 :'*+?01MPD ,WA1 :'*+?01 MED ,WA1
(F1@.P)/) 'B,L@ +'0>?V[1'B,L@ 'B,L@ +'0>?V[1'B,L@ 'B,L@ +'0>?V[1'B,L@ 'B,L@ YZ[F1@.P)/j.[
50% MED (H@?t=> 3- 75% MED (H@?t=> 3- V@? MPD t[@j?W tq/ 6MED (2-
5 ('BE/VWA)B:.@IU +S0>? 5 ('BE/VWA)B:.@IU +S0>? )@?@'t:'*+?01j.[ 6MED) (H@?t=> 2 ('BE/
F1@.P)/AJW@/1[AJ F1@.P)/AJW@/1[AJ +'0>? 0.5-2 J/cm2 VWA)B:.@IU
10%FA/ MED 10%FA/ MED (H@?t=> 2 ('BE/VWA
)B:.@IU +S0>?F1@.
40%VWA)B:.@IU
R1,HW@P./ IKB/R@,
1BE1j?W(H'+S0>?
?@,,HW@ 20% F1@.
)l/)Q. 12 J/ cm2
Efficacy GD>1.=FqE1 >'[AJK* 70 GD>1.=FqE1 >'[AJK* 47 )@?@'t<N@YI[GD>1)/C GD>1.=FqE1 >'[AJK* 75
(:'*)0<T0k@S) Y1,@'pq,L@IKB/,@' Y1,@'pq,L@IKB/,@' (remission) 70-90% (PASI 75) IKB/R@,
'B,L@.[HJP)/C1GD1> 'B,L@.[HJP)/C1GD1> FA/Gl:[ rHJ (H@? Gl[:rHJ'B,L@+{K=>J 6.2
('q>/I1q>/FA/'W@/,@J ('q>/I1q>/FA/'W@/,@J )*.H,Y1,@'{@J ('BE/ ((QMk@S
Gl[:rHJ9Y1 11 '@J GD>1 ?=+S=J/Gl[:rHJ1 Y1 11 1[AJ,HW@ NB-UVB FA/IKB,x@1B2)
I@JI?. '@JGD>1I@JI?. PVW:'*)0<T0k@SA@R
:'*)0<T0k@S.=,HW@ ((QMk@SFA/ .=,HW@ ((QMk@SFA/
BB-UVB ((QMk@S IKB,x@1B1) IKB,x@1B1)
FA/IKB,x@1B1)
Safety Photodamage, PMLE, skin aging, skin cancer Photodamage, skin Erythema, blisters,
((H@?:KA.kBJ) aging, increased risk hyperpigmentation,
on nonmelanoma erosions. Long term
skin cancers ± side effects not yet
Melanoma, ±ocular clear but likely
damage similar to NB-UVB

97
Contraindicatons Absolute : severe photosensitivity Absolute : Absolute :
(F[AI[@?YZ[) Relative : photosensitizing drugs, melanoma - Severe - Photosensitivity
and nonmelanoma skin cancer Photosensitivity Relative :
- Lactation - photosensitizing
- Melanoma drugs
Relative : - melanoma and
- age < 10 yrs nonmelanoma skin
- pregnancy cancer
- photosensitizing
drugs
- nonmelanoma skin
cancer
- severe organ
dysfunction
I?@J+IVQ ,'M=YZ['WH?,BC coal tar (Goeckerman P1*1N@{@JP)/j?W +:;1,@''B,L@+{S@*
regimen) anthralin (Ingram regimen) I'DAJ@ +,01 200('BE/ I'DA GD>1<=+> :;1&'( &.J
'BC:'*<@1 +S0>?:'*)0<T0k@S,@''B,L@?@, F1@.P)/)*)? G0HI1B/:,V0j?W
FqE1 ≤2000 J/ cm2 RN@+:;1V[A/'BCP)/
,@''B,L@'WH?,BC oral
retinoids ZWHJK.
:'0?@MP)/ UVA
PK*K.AQCBV0,@'MU,@'
+,0.?*+'-/G0HI1B/
Z10. squamous cell
CA j.['[AJK* 30(33)

Minimal erythema dose (MED) I?@Jtq/:'0?@MP)/1[AJ<=>)Q.<=<> N@YI[G0HI1B/<=><N@<.)AC?=,@'P./

&.JAW@1GK<=> 24 ZB>H&?/IKB/<N@<.)AC

98
 >?@A3B<CDE 1

Psoriasis Area and Severity Index (PASI)

Tick ONE box for each region for A,B,C,D

Head(h) Upper limb(u) Trunk(t) Lower limb(l)
A. Extent of None (0) ! ! ! !
Involvement (%) <10 (1) ! ! ! !
Tick one box for 10-30 (2) ! ! ! !
each body 30-50 (3) ! ! ! !
region. 50-70 (4) ! ! ! !
70-90 (5) ! ! ! !
90-106 (6) ! ! ! !
B. Erythema (E) None (0) ! ! ! !
score Slight (1) ! ! ! !
Tick one box for Moderate (2) ! ! ! !
each body Severe (3) ! ! ! !
region. Very severe (4) ! ! ! !
C. Induration (I) None (0) ! ! ! !
score Slight (1) ! ! ! !
Tick one box for Moderate (2) ! ! ! !
each body Severe (3) ! ! ! !
region. Very severe (4) ! ! ! !
D. Desquamation None (0) ! ! ! !
(D) score Slight (1) ! ! ! !
Tick one box for Moderate (2) ! ! ! !
each body Severe (3) ! ! ! !
region. Very severe (4) ! ! ! !
PASI SCORE = 0.1 (Eh + lh + Dh)Extent(h) + 0.2 (Eu + lu + Du)Extent(u) + 0.3 (Et + lt +
Dt)Extent(t)+ 0.4 (El + ll + Dl)Extent(l)

99
 >?@A3B<CDE 2
\]]97]^?_B`5@ab>?c2DB4d678AefgBh ijk@A4Bl3`8
DLQI Score: _____________

cde fgh ijkl mghn ______ op mgfqd____________________

Case No. _______rstuqv ___ / ______ / ______

wnxoyz{l|}~ml•ÄÄ{mÄÅgÇtqÉ cdÑvmoyzcÇktrÖg ÜÑvtÜkritsluágàiâcäkxoãjigäsÄ|nåÇgätâmhcdqhlàxàtfÖrlitçvl{soxgi}uqvÜÖgtÇg?

<kab?d7]@o?^?_j5iCo?;@kpE78l_?i aq8r32s78C?86B?_p7 (67@B?_<kab?d7]@o?^?_Ca<6f7)

1. fÖrl{soxgi}uqvÜÖgtÇg |nåÇqmgägy|st, cwèÄ, orx, iyÑmorxc{qhr uqvÜrk itslÇgä (3) Çgä

tâmhcdqhlàx
(2) ogtäêgl
(1) cêèätâmh
(0) ëÇÖÇqcêh
2. fÖrl{soxgi}uqvÜÖgtÇg ÜÑvtÜkritsluágàiâ|nåyíâ{çämsÄmgh, ~gx|rgÇÇsvtàw Çgätâmh (3) Çgä
cdqhlàx
(2) ogtäêgl
(1) cêèätâmh
(0) ëÇÖÇqcêh

3. àtfÖrl{soxgi}uqvÜÖgtÇg ÜÑvtÜkritsluágàiâ|nåÇqoãjigàtägymmäwgäÄâgtëo (3) Çgä

wsÄwÖghìÑÉm{kt|âg, xí•êÄâgt iyÑmxí•ê{rt Çgätâmhcdqhlàx
(2) ogtäêgl
(1) cêèätâmh
(0) ëÇÖÇqcêh ëÇÖÇq|rgÇcäqvhr~âml
4. fÖrl{soxgi}uqvÜÖgtÇg ÜÑvtÜkritsl~ml|nå ÇqÜêäyzuÄîÖmägycêÑmäc{ÑÉmÜâguqvwz{rÇ (3) Çgä
à{Ö Çgätâmhcdqhlàx
(2) ogtäêgl
(1) cêèätâmh
(0) ëÇÖÇqcêh ëÇÖÇq|rgÇcäqvhr~âml

5. fÖrl{soxgi}uqvÜÖgtÇg ÜÑvtÜkritsl~ml|nå ÇqÜêäyzuÄîÖmägyc~âg{sl|Ç iyÑmîÖm (3) Çgä

äkwäyyÇàthgÇrÖgl Çgätâmhcdqhlàx
(2) ogtäêgl
(1) cêèätâmh
(0) ëÇÖÇqcêh ëÇÖÇq|rgÇcäqvhr~âml
6. fÖrl{soxgi}uqvÜÖgtÇg ÜÑvtÜkritslÇqÜêäyzuÄîÖmägycêÖtäqïg ägymmääágêslägh (3) Çgä
~ml|nå Çgätâmhcdqhlàx
(2) ogtäêgl ëÇÖÇq|rgÇcäqvhr~âml

100
 (1) cêèätâmh
(0) ëÇÖÇqcêh

7. fÖrl{soxgi}uqvÜÖgtÇg ÜÑvtÜkritslÇqÜêuágàiâ|nå~gxlgtiyÑm~gxcyqhtiyÑmëÇÖ Çq
ëÇÖÇq|rgÇcäqvhr~âml
ëÇÖÇq
Åâg ñëÇÖÇóq àtfÖrl{soxgi}uqvÜÖgtÇg ÜÑvtÜkritsluágàiâÇq|nåÇqoãjigàtägy (3) Çgä
uáglgt iyÑm ägycyqht Çgätâmhcdqhlàx
(2) ogtäêgl
(1) cêèätâmh
(0) ëÇÖÇqcêh

8. fÖrl{soxgi}uqvÜÖgtÇg ÜÑvtÜkritsl~ml|nå ëxâ{yâgloãjigàiâäsÄ|íÖ|yml iyÑmjgîk (3) Çgä

iyÑmcdÑmv t{tku Çgätâmhcdqhlàx
(2) ogtäêgl
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in high risk populations: Recommendation of the advisory Council for the elimination of tuberculosis. MMWR
1995

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