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Treatment recommendations to improve outcomes in psoriasis care
Up-to-Date Treatment Recommendations for Moderate to Severe Psoriasis

Released: June 25, 2025

Expiration: June 24, 2026

Benjamin Ungar
Benjamin Ungar, MD
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Key Takeaways
  • The first step after diagnosing psoriasis is determining disease severity, which informs treatment selection and patient candidacy for systemic therapy.
  • Psoriatic arthritis, inflammatory bowel disease, obesity, metabolic syndrome, and cardiovascular disease are key comorbidities that should inform the care of patients with psoriasis.
  • Although older systemic therapies like TNF-α inhibitors are a mainstay treatment, newer biologic agents such as IL-17 and IL-23 inhibitors have shown greater efficacy in treating psoriasis.

We are fortunate today to have many FDA-approved treatments that are safe, efficacious, and truly help our patients with psoriasis. Although this increased number of choices can make treatment selection seem more complicated, there are principles that can help guide your approach to care. These principles will make the decision-making process more straightforward and ensure that patients achieve excellent outcomes.

Disease Severity and Key Comorbidities
Most patients present to dermatology with their skin condition (or their plaque psoriasis); it is a systemic, multiorgan, and chronic disease. Therefore, healthcare professionals (HCPs) must be mindful of the potential for other conditions that play a role in selecting the optimal treatment. Furthermore, the first point in the decision-making process is determining disease severity. If patients’ skin involvement is relatively limited, then topical therapies are appropriate. But for skin involvement that is more significant (ie, moderate to severe), topical therapies often are insufficient for treatment, so we must go beyond that to systemic therapies. The exception to this includes patients with special site involvement (ie, genitals, scalp) that can have a disparate impact on their quality of life. That increases their disease severity relative to the body surface area involved.

Another key consideration in treatment selection is knowing if patients with psoriasis also have psoriatic arthritis. HCPs should remember that psoriatic arthritis, skin area involvement, and disease severity may not go hand in hand. Even if patients have relatively limited skin involvement, they can have significant psoriatic arthritis. In addition, it is not always the case that these patients present with both diseases at the same time. Therefore, anyone with psoriasis should be screened for psoriatic arthritis. And if joint swelling or pain is present, then that necessitates systemic treatment.

It is also important to remember that psoriasis is associated with obesity, metabolic syndrome, and cardiovascular disease. Although these comorbidities are not considerations that typically play a role in treatment selection from a dermatologic perspective, it is nevertheless important to think about how these comorbidities affect patients’ overall health. In particular, obesity is quite common and associated with a proinflammatory state like psoriasis. Because of disease responses beyond one’s direct cardiovascular health, it is critical that patients improve their overall health. So, whether HCPs are screening and referring patients to appropriate specialists or monitoring patients in their own office, this is a crucial component of our care delivery. Even if patients have milder to moderate disease, they may be candidates for systemic treatment if they also have obesity or other signs of metabolic syndrome. HCPs should keep a close eye on patients with the help of cardiology and follow-up on addressing patients’ systemic inflammatory state to help improve outcomes from that perspective.

The Evolving Treatment Landscape
The treatment options for psoriasis can be grouped by their mechanisms of action/drug classes and should guide conversations as well as decision-making. Some considerations when distinguishing among these classes are administration route, administration frequency, and more. The treatment options for patients with moderate to severe disease who are candidates for systemic therapy include biologics like TNF-α inhibitors, IL-23 inhibitors, IL-12/23 inhibitors, as well as IL-17 inhibitors. Whereas these are all injectables, there are nonbiologic oral options, such as TYK2 inhibitors, phosphodiesterase 4 inhibitors, and JAK inhibitors. Some of these are also approved to treat psoriatic arthritis, so there are many options available there, too.

If patients with psoriasis have comorbid inflammatory bowel disease (IBD), I would remove the IL-17 inhibitors from consideration. This is because these agents can worsen or trigger new onset IBD. For those with a history of depression or mood changes, I would be very cautious about using brodalumab or bimekizumab. These agents have either a boxed warning (brodalumab) or a warning noted on the prescribing information regarding a possible increased risk of suicidal ideation and behavior (bimekizumab). Follow-up studies and analysis have suggested that these risks may be overstated, however it is important to be aware of the prescribing information. In addition, apremilast is a PDE4 inhibitor that has a warning for worsening or emerging depression, suicidal thoughts, and mood changes.

In general, TNF-α inhibitors are not likely to play a role as first-line or second-line treatment at this point. That is because these agents tend to be less efficacious compared with the newer IL-17 and IL-23 inhibitors. Although TNF-α inhibitors can be appropriate in many cases, they are not going to be a treatment option that we reach for initially.

Once HCPs have the different drug classes laid out and are thinking about the role of comorbidities in terms of which agents should be avoided, there are some other relatively minor considerations that can further inform the conversation during the shared decision-making process. HCPs can ask patients what is important to them. Some may prefer oral therapies vs injectable agents. And this is something that is worth discussing. There also is a possibility for patients to prefer injectable agents because of their periodic dosing vs taking daily oral pills. Furthermore, dosing frequency can change with the different treatment options. Moving beyond the loading dose, which can be complicated or more frequent for some agents, IL-17 inhibitors typically are given monthly or every two months as maintenance whereas IL-23 inhibitors can be given less frequently, ranging from once every 2-3 months as maintenance, depending on the specific agent. Therefore, dosing frequency may play a role in patients’ preferences as well.

Your Thoughts
How often are you using new and emerging IL-17 and IL-23 inhibitors to treat your patients with moderate to severe psoriasis? You can get involved in the conversation by answering the poll question and posting a comment below.

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How often are you using new and emerging IL-17 and IL-23 inhibitors to treat your patients with moderate to severe psoriasis?

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