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created with the collaboration of experts from all regions of Brazil is shown below &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In preparing this consensus&#44; the stratification of the levels of evidence and their grade of recommendation was used&#44; according to the project guidelines of the Brazilian Medical Association &#40;AMB&#41;&#44; described below&#58;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Grade of recommendation and strength of evidence<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">A&#58; Experimental or observational studies of higher consistency&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">B&#58; Experimental or observational studies of lower consistency&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">C&#58; Case reports &#40;uncontrolled studies&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">D&#58; Opinion without critical evaluation consensus based&#44; physiological studies or animal models&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In this document&#44; we use the Delphi tool to obtain answers to non-consensual questions in the literature&#44; through the anonymous collection of data among specialists on the subject&#46; The Delphi method is defined as &#8220;a data collection technique used to obtain consensus from a group of experts on a particular subject&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Thus&#44; a new treatment flowchart for severe psoriasis was validated and strategies were defined for the migration of therapies&#44; designed for adoption in the Brazilian public or private health context&#44; based on hearing the opinions of experts engaged in these health systems &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Two rounds were held with the participation of 66 dermatologists who authored this consensus&#44; from all regions of the country&#44; with experience in the treatment of psoriasis&#46; The online voting system &#40;Survey Monkey&#174;&#41; was used&#44; and the agreement of at least 70&#37; of the experts was considered a consensus&#46; The data obtained were statistically analyzed&#46; The sample was obtained by appointment and submitted to a randomness test&#44; which resulted in the non-rejection of randomness&#44; with a significance of 5&#37;&#46; The results are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Mediated by the Brazilian Society of Dermatology&#44; this instrument represents progress in the standardization of conduct&#44; whether in public or private care&#44; based on what we have available or aspire for the treatment of severe psoriasis&#46; The existence of dissensus stimulates further debate on controversial and unanswered topics in the medical literature&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The high percentage of agreement in the other topics provides subsidies to professionals working in the area for the best therapeutic choices&#44; instead of decisions based solely on the prescriber&#39;s experience&#46; Such transparency is essential for everyone involved&#44; whether managers of the supplementary health system or the Brazilian Unified Health System &#40;SUS&#41;&#44; physicians&#44; patients&#44; their families&#44; and patient associations&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0075" class="elsevierStylePara elsevierViewall">Brazilian Society of Dermatology &#40;SBD&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0080" class="elsevierStylePara elsevierViewall">Ricardo Romiti&#58; Design and planning of the study&#59; data collection&#44; or data analysis and interpretation&#59; statistical analysis&#59; drafting and editing of the manuscript or critical review of important intellectual content&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; critical review of the literature&#59; approval of the final version of the manuscript&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Andr&#233; Vicente Esteves de Carvalho&#58; Design and planning of the study&#59; data collection&#44; or data analysis and interpretation&#59; statistical analysis&#59; drafting and editing of the manuscript or critical review of important intellectual content&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; critical review of the literature&#59; approval of the final version of the manuscript&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Gleison V Duarte&#58; Design and planning of the study&#59; data collection&#44; or data analysis and interpretation&#59; statistical analysis&#59; drafting and editing of the manuscript or critical review of important intellectual content&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; critical review of the literature&#59; approval of the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">Romiti R is&#47;has served as a scientific consultant&#44; speaker&#44; or clinical study investigator for Abbvie&#44; Boehringer-Ingelheim&#44; Galderma&#44; Janssen&#44; Lilly&#44; Leo-Pharma&#44; Novartis&#44; Pierre-Fabre&#44; 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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article&#58; Romiti R&#44; Carvalho AVE&#44; Duarte GV&#59; Grupo de Trabalho do Consenso Brasileiro de Psor&#237;ase da Sociedade Brasileira de Dermatologia&#46; Brazilian Consensus on Psoriasis 2020 and Treatment Algorithm of the Brazilian Society of Dermatology&#46; An Bras Dermatol&#46; 2021&#59;96&#58;778&#8211;81&#46;</p>"
      ]
      2 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Dermatology Department of Hospital das Cl&#237;nicas da Universidade de S&#227;o Paulo&#44; S&#227;o Paulo&#44; SP&#59; Hospital Moinhos de Vento de Porto Alegre&#44; Porto Alegre&#44; RS&#59; Instituto Bahiano de Imunoterapias&#44; Salvador&#44; BA&#44; Brazil&#46;</p>"
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            "etiqueta" => "Appendix A"
            "titulo" => "Members of the Working Group of the Brazilian Consensus on Psoriasis of the Brazilian Society of Dermatology"
            "identificador" => "sec0020"
          ]
        ]
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Geographical distribution of Brazilian experts participating in the Brazilian Consensus on Psoriasis 2020&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Algorithm for the Treatment of Severe Psoriasis of the Brazilian Society of Dermatology&#44; 2020&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Classification of respondents&#39; opinions&#44; per question&#44; Brazil &#8211; 2020</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Consensus criterion&#58; 70&#37; of agreement or more&#46;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Questions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Answers with the highest percentage of agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Classification&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q1&#58; What is the criterion for changing from one therapy to another&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unavailability&#44; intolerance&#44; failure or absolute or relative contraindication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q2&#58; What to do if the patient does not reach PASI 50 and DLQI&#8201;&#60;&#8201;5 &#40;primary failure&#41; with oral methotrexate at a dose of 15&#8201;mg&#47;week within 8 weeks&#44; with full access&#47;availability&#63;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46; Medication change&#58; 54&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dissensus</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 MTX dose optimization up to 25&#8201;mg&#47;week&#44; regardless of administration route&#58; 46&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q3&#58; If the patient does not reach PASI 75 and DLQI&#8201;&#60;&#8201;5 &#40;secondary failure&#41; with oral methotrexate at a dose of 15&#8201;mg&#47;week within 8 weeks&#44; what is the suggested approach when there is full access&#47;availability&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MTX dose optimization up to 25&#8201;mg&#47;week&#44; regardless of administration route &#40;oral&#47;parenteral&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q4&#58; If the patient does not reach PASI 50 and DLQI&#8201;&#60;&#8201;5&#44; acitretin failure should be considered after&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#8211;16 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q5&#58; If the patient does not reach PASI 50 and DLQI&#8201;&#60;&#8201;5&#44; primary failure of cyclosporine &#40;up to 5&#8201;mg&#47;kg&#41; should be considered in&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Up to 4 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q6&#58; What is the therapeutic goal to be achieved in patients using biologicals&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PASI 90 or absolute PASI &#60;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q7&#58; What is your degree of agreement with the sentence&#58; &#34;In patients with primary failure with an immunobiological&#44; the medication should be changed to another one with a different mechanism of action&#34;&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#37; of agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q8&#58; What is your degree of agreement with the sentence&#58; &#34;Patients with secondary failure with a biological mechanism of action can benefit from a change to a drug of the same class&#34;&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&#37; of agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dissensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q9&#58; From 1&#8211;10 what is your degree of agreement with the proposed flowchart&#63; &#40;1&#8201;&#61;&#8201;strongly disagree&#59; 10&#8201;&#61;&#8201;strongly agree&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&#46;4&#37; of agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Authors of the Brazilian Consensus on Psoriasis 2020&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Silvio Alencar Marques &#40;SP&#41;&#44; Luciane D&#46; B&#46; Miot &#40;SP&#41;&#44; Maria Cecilia de C&#46; Bortoletto &#40;SP&#41;&#44; Arn&#243;bio da Penha Pach&#234;co &#40;RN&#41;&#44; Adriane Reichert Faria &#40;PR&#41;&#44; Caio Cesar S&#46; de Castro &#40;PR&#41;&#44; Luciena C&#46; Martins Ortigosa &#40;SP&#41;&#44; Xinaida Lima &#40;CE&#41;&#44; Sueli Carneiro &#40;RJ&#41;&#44; Marcelo Pinheiro &#40;SP&#41;&#44; Mayra Ianhez &#40;GO&#41;&#44; Monica Nunes de Souza Santos &#40;AM&#41;&#44; Roberta Buense Bedrikow &#40;SP&#41;&#44; Rosana Lazzarini &#40;SP&#41;&#44; Joa&#771;o Carlos R&#46; Avelleira &#40;RJ&#41;&#44; Aline Bressan &#40;RJ&#41;&#44; Andre&#769; Lui&#769;s da Silva Hirayama &#40;SP&#41;&#44; Sineida B&#46; Ferreira &#40;PR&#41;&#44; Adriana M&#46; Porro &#40;SP&#41;&#44; Alexandre Gripp &#40;RJ&#41;&#44; Ivonise Follador &#40;BA&#41;&#44; Juliana Nakano &#40;SP&#41;&#44; Andre&#769;a Machado C&#46; Ramos &#40;MG&#41;&#44; Aripuan&#227; Terena &#40;MG&#41;&#44; Francisca Regina O&#46; Carneiro &#40;PA&#41;&#44; Vivianne Lira da C&#46; Costa &#40;RN&#41;&#44; Anber A&#46; Tanaka &#40;PR&#41;&#44; Lincoln Fabricio &#40;PR&#41;&#44; Leticia Oba Galv&#227;o &#40;DF&#41;&#44; Gladys A&#46; Martins &#40;DF&#41;&#44; Ricardo Romiti &#40;SP&#41;&#44; Clarice Kobata &#40;SP&#41;&#44; Michelle dos Santos Diniz &#40;MG&#41;&#44; Cacilda da Silva Souza &#40;SP&#41;&#44; Renata F&#46; Magalh&#227;es &#40;SP&#41;&#44; Dimitri Luz &#40;SP&#41;&#44; Andr&#233; Vicente E&#46; de Carvalho &#40;RS&#41;&#44; Jaquelini Silva &#40;RS&#41;&#44; Claudia Maia &#40;RJ&#41;&#44; Paulo A&#46; Oldani Felix &#40;RJ&#41;&#44; Wagner Galv&#227;o &#40;SP&#41;&#44; Maria Victoria Su&#225;rez Restrepo &#40;SP&#41;&#44; Cynthia C&#46; F&#46; Mota &#40;SP&#41;&#44; Eduardo L&#46; Martins &#40;SP&#41;&#44; Daniel H&#46; Nunes &#40;SC&#41;&#44; Andreia Costa &#40;SP&#41;&#44; Mauricio Conti &#40;SC&#41;&#44; Esther B&#46; Palitot &#40;PB&#41;&#44; Ana Carolina B Arruda &#40;SP&#41;&#44; Claudio Lerer &#40;DF&#41;&#44; Livia Souto &#40;RJ&#41;&#44; Roberto Souto &#40;RJ&#41;&#44; Jane Bonf&#225; &#40;RJ&#41;&#44; Ver&#244;nica Bogado &#40;RJ&#41;&#44; Sidney Augusto da C&#46; Costa &#40;RN&#41;&#44; Domingos Jord&#227;o Neto &#40;SP&#41;&#44; Luiza O&#46; Keiko &#40;SP&#41;&#44; Bruna Falcone &#40;SP&#41;&#44; Luna Azulay Abulafia &#40;RJ&#41;&#44; Aldejane Gurgel de A&#46; Rodrigues &#40;PE&#41;&#44; Tania F&#46; Cestari &#40;RS&#41;&#44; Juliana Bozza &#40;RS&#41;&#44; Marcelo Arnone &#40;SP&#41;&#44; Maria Denise F&#46; Takahashi &#40;SP&#41;&#44; Heitor de S&#225; Gon&#231;alves &#40;CE&#41;&#44; Paulo Eduardo de S&#225; Gon&#231;alves &#40;CE&#41;&#44; Gleison V&#46; Duarte &#40;BA&#41;&#44; Maria de F&#225;tima S&#46; Paim de Oliveira &#40;BA&#41;&#46;&nbsp;\t\t\t\t\t\t\n
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                        0 => array:2 [
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                          "autores" => array:4 [
                            0 => "R&#46; Romiti"
                            1 => "M&#46; Amone"
                            2 => "A&#46; Menter"
                            3 => "H&#46;A&#46; Miot"
                          ]
                        ]
                      ]
                    ]
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Int J Dermatol&#46;"
                        "fecha" => "2017"
                        "volumen" => "56"
                        "paginaInicial" => "167"
                        "paginaFinal" => "168"
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                    0 => array:2 [
                      "titulo" => "Humanistic and economic impact of moderate to severe plaque psoriasis in Brazil"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "N&#46; Lopes"
                            1 => "L&#46;L&#46;S&#46; Dias"
                            2 => "L&#46; Azulay-Abulafia"
                            3 => "L&#46;K&#46;M&#46; Oyafuso"
                            4 => "M&#46;V&#46; Suarez"
                            5 => "L&#46; Fabricio"
                          ]
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Research Letter
Brazilian Consensus on Psoriasis 2020 and Treatment Algorithm of the Brazilian Society of Dermatology
Ricardo Romitia,
Corresponding author
rromiti@hotmail.com

Corresponding author.
, André Vicente E. de Carvalhob, Gleison V. Duartec, Grupo de Trabalho do Consenso Brasileiro de Psoríase da Sociedade Brasileira de Dermatologia 1
a Dermatology Department of Hospital das Clínicas da Universidade de São Paulo, SP, Brazil
b Hospital Moinhos de Vento de Porto Alegre, Porto Alegre, RS, Brazil
c Instituto Bahiano de Imunoterapias, Salvador, BA, Brazil
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was identified in relation to age groups&#44; which was 0&#46;58&#37; &#40;95&#37; CI 0&#46;31&#37; to 0&#46;84&#37;&#41; under the age of 30&#59; 1&#46;39&#37; &#40;95&#37; CI 1&#46;10&#37; to 1&#46;74&#37;&#41; between 30 and 60 years old&#59; and 2&#46;29&#37; &#40;95&#37; CI 1&#46;71&#37; to 2&#46;84&#37;&#41; in individuals over 60 years&#46; The geographical regions of the country differed in terms of disease prevalence &#40;p&#8201;&#61;&#8201;0&#46;02&#41;&#44; with higher indicators in the South and Southeast regions&#44; in contrast to the Midwest&#44; North and Northeast regions&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In parallel&#44; 73&#46;4&#37; of Brazilian patients with moderate to severe psoriasis report impaired health-related quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The Brazilian Consensus on Psoriasis 2020 and the Treatment Algorithm of the Brazilian Society of Dermatology &#40;SBD&#41;&#44; created with the collaboration of experts from all regions of Brazil is shown below &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In preparing this consensus&#44; the stratification of the levels of evidence and their grade of recommendation was used&#44; according to the project guidelines of the Brazilian Medical Association &#40;AMB&#41;&#44; described below&#58;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Grade of recommendation and strength of evidence<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">A&#58; Experimental or observational studies of higher consistency&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">B&#58; Experimental or observational studies of lower consistency&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">C&#58; Case reports &#40;uncontrolled studies&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">D&#58; Opinion without critical evaluation consensus based&#44; physiological studies or animal models&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In this document&#44; we use the Delphi tool to obtain answers to non-consensual questions in the literature&#44; through the anonymous collection of data among specialists on the subject&#46; The Delphi method is defined as &#8220;a data collection technique used to obtain consensus from a group of experts on a particular subject&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Thus&#44; a new treatment flowchart for severe psoriasis was validated and strategies were defined for the migration of therapies&#44; designed for adoption in the Brazilian public or private health context&#44; based on hearing the opinions of experts engaged in these health systems &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Two rounds were held with the participation of 66 dermatologists who authored this consensus&#44; from all regions of the country&#44; with experience in the treatment of psoriasis&#46; The online voting system &#40;Survey Monkey&#174;&#41; was used&#44; and the agreement of at least 70&#37; of the experts was considered a consensus&#46; The data obtained were statistically analyzed&#46; The sample was obtained by appointment and submitted to a randomness test&#44; which resulted in the non-rejection of randomness&#44; with a significance of 5&#37;&#46; The results are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Mediated by the Brazilian Society of Dermatology&#44; this instrument represents progress in the standardization of conduct&#44; whether in public or private care&#44; based on what we have available or aspire for the treatment of severe psoriasis&#46; The existence of dissensus stimulates further debate on controversial and unanswered topics in the medical literature&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The high percentage of agreement in the other topics provides subsidies to professionals working in the area for the best therapeutic choices&#44; instead of decisions based solely on the prescriber&#39;s experience&#46; Such transparency is essential for everyone involved&#44; whether managers of the supplementary health system or the Brazilian Unified Health System &#40;SUS&#41;&#44; physicians&#44; patients&#44; their families&#44; and patient associations&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0075" class="elsevierStylePara elsevierViewall">Brazilian Society of Dermatology &#40;SBD&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#39; contributions</span><p id="par0080" class="elsevierStylePara elsevierViewall">Ricardo Romiti&#58; Design and planning of the study&#59; data collection&#44; or data analysis and interpretation&#59; statistical analysis&#59; drafting and editing of the manuscript or critical review of important intellectual content&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; critical review of the literature&#59; approval of the final version of the manuscript&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Andr&#233; Vicente Esteves de Carvalho&#58; Design and planning of the study&#59; data collection&#44; or data analysis and interpretation&#59; statistical analysis&#59; drafting and editing of the manuscript or critical review of important intellectual content&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; critical review of the literature&#59; approval of the final version of the manuscript&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Gleison V Duarte&#58; Design and planning of the study&#59; data collection&#44; or data analysis and interpretation&#59; statistical analysis&#59; drafting and editing of the manuscript or critical review of important intellectual content&#59; collection&#44; analysis&#44; and interpretation of data&#59; effective participation in research orientation&#59; critical review of the literature&#59; approval of the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">Romiti R is&#47;has served as a scientific consultant&#44; speaker&#44; or clinical study investigator for Abbvie&#44; Boehringer-Ingelheim&#44; Galderma&#44; Janssen&#44; Lilly&#44; Leo-Pharma&#44; Novartis&#44; Pierre-Fabre&#44; Pfizer&#44; UCB&#44; and TEVA&#46;Carvalho AVE is&#47;has served as a scientific consultant&#44; speaker&#44; or clinical study investigator for Abbvie&#44; Boehringer-Ingelheim&#44; Janssen&#44; Lilly&#44; Leo-Pharma&#44; Novartis&#44; and UCB&#46;Duarte GV is&#47;has served as a scientific consultant&#44; speaker&#44; or clinical study investigator for Abbvie&#44; Bayer&#44; Janssen&#44; Leo-Pharma&#44; Galderma&#44; Novartis&#44; Pfizer&#44; and UCB&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article&#58; Romiti R&#44; Carvalho AVE&#44; Duarte GV&#59; Grupo de Trabalho do Consenso Brasileiro de Psor&#237;ase da Sociedade Brasileira de Dermatologia&#46; Brazilian Consensus on Psoriasis 2020 and Treatment Algorithm of the Brazilian Society of Dermatology&#46; An Bras Dermatol&#46; 2021&#59;96&#58;778&#8211;81&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Dermatology Department of Hospital das Cl&#237;nicas da Universidade de S&#227;o Paulo&#44; S&#227;o Paulo&#44; SP&#59; Hospital Moinhos de Vento de Porto Alegre&#44; Porto Alegre&#44; RS&#59; Instituto Bahiano de Imunoterapias&#44; Salvador&#44; BA&#44; Brazil&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Classification of respondents&#39; opinions&#44; per question&#44; Brazil &#8211; 2020</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Consensus criterion&#58; 70&#37; of agreement or more&#46;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Questions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Answers with the highest percentage of agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Classification&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q1&#58; What is the criterion for changing from one therapy to another&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unavailability&#44; intolerance&#44; failure or absolute or relative contraindication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q2&#58; What to do if the patient does not reach PASI 50 and DLQI&#8201;&#60;&#8201;5 &#40;primary failure&#41; with oral methotrexate at a dose of 15&#8201;mg&#47;week within 8 weeks&#44; with full access&#47;availability&#63;</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46; Medication change&#58; 54&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dissensus</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 MTX dose optimization up to 25&#8201;mg&#47;week&#44; regardless of administration route&#58; 46&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q3&#58; If the patient does not reach PASI 75 and DLQI&#8201;&#60;&#8201;5 &#40;secondary failure&#41; with oral methotrexate at a dose of 15&#8201;mg&#47;week within 8 weeks&#44; what is the suggested approach when there is full access&#47;availability&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MTX dose optimization up to 25&#8201;mg&#47;week&#44; regardless of administration route &#40;oral&#47;parenteral&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q4&#58; If the patient does not reach PASI 50 and DLQI&#8201;&#60;&#8201;5&#44; acitretin failure should be considered after&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#8211;16 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q5&#58; If the patient does not reach PASI 50 and DLQI&#8201;&#60;&#8201;5&#44; primary failure of cyclosporine &#40;up to 5&#8201;mg&#47;kg&#41; should be considered in&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Up to 4 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q6&#58; What is the therapeutic goal to be achieved in patients using biologicals&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PASI 90 or absolute PASI &#60;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q7&#58; What is your degree of agreement with the sentence&#58; &#34;In patients with primary failure with an immunobiological&#44; the medication should be changed to another one with a different mechanism of action&#34;&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#37; of agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q8&#58; What is your degree of agreement with the sentence&#58; &#34;Patients with secondary failure with a biological mechanism of action can benefit from a change to a drug of the same class&#34;&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">51&#37; of agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dissensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Q9&#58; From 1&#8211;10 what is your degree of agreement with the proposed flowchart&#63; &#40;1&#8201;&#61;&#8201;strongly disagree&#59; 10&#8201;&#61;&#8201;strongly agree&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&#46;4&#37; of agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 03650596
Original language: English
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