The correct answer is C. Continue guselkumab, start topical steroids and low-dose methotrexate.

Combination therapy with MTX and biologics may serve as an efficacious treatment for psoriasis patients with an inadequate response to DMARD monotherapy. Adjuvant topical therapy and low-dose methotrexate to guselkumab may help preserve duration of her response to guselkumab.

The patient’s uncontrolled symptoms of psoriatic arthritis make nbUVB (A) and topical steroid monotherapy (B) inappropriate choices. Her history of renal disease makes ( E) cyclosporine a bad choice. Switching to a different biologic (D) is an option. However, given that transient stress could be driving her current flare and she has lost efficacy to multiple other biologics in the past, adding adjuvant topical therapy and low-dose methotrexate to guselkumab may help preserve duration of her response to guselkumab. Combination therapy with MTX and biologics may serve as an efficacious treatment for psoriasis patients with an inadequate response to DMARD monotherapy.

References:

Zachariae C, Mørk NJ, Reunala T, Lorentzen H, Falk E, Karvonen SL, Johannesson A, Claréus B, Skov L, Mørk G, Walker S, Qvitzau S. The combination of etanercept and methotrexate increases the effectiveness of treatment in active psoriasis despite inadequate effect of methotrexate therapy. Acta Derm Venereol. 2008;88(5):495-501. doi: 10.2340/00015555-0511. PMID: 18779890.