- They have tried and failed topical therapy;
- They have psoriasis involving the scalp, face, palms, soles, nails or genitals; or
- They have >10% BSA involvement.
The IPC hopes these criteria can be used to effectively identify patients who are suffering a reduced quality of life due to their disease and provide them with appropriate systemic therapy.
Treatment
In terms of the current psoriasis treatment landscape, Dr. Fernandez pointed out that 11 new biologic agents have been approved since 2004, including tumor necrosis alpha (TNF-α) inhibitors, interleukin 12/23 (IL-12/23) inhibitors, IL-17 inhibitors and IL-23 inhibitors.
Dr. Fernandez stated that the IL-23 inhibitors, in particular, were heralded as potential game-changing medications when approved because IL-23 is viewed as the master cytokine in the pathogenesis of psoriasis. Indeed, the data so far do not dispute the idea that IL-23 inhibitors may qualify as immune disruptors that can have significant disease-modifying effects.
In one study by Reich et al., researchers evaluated the five-year maintenance of clinical response and health-related quality-of-life improvements in patients with moderate to severe psoriasis who were treated with guselkumab, an IL-23 inhibitor. The researchers found that, after five years of treatment, more than one in two patients treated with guselkumab achieved complete resolution of psoriasis.4 Very few patients dropped out over the course of the study.
After five years of treatment, more than one in two patients treated with guselkumab achieved complete resolution of psoriasis.
Efficacy, as measured by Psoriasis Area and Severity Index (PASI) 90 and 100 scores, is being seen with risankizumab and bimekizumab as well.
For a systematic review of pharmacologic treatments of chronic plaque psoriasis, Dr. Fernandez described a Cochrane Review article on this subject published in 2022. This review indicated that IL-17 and IL-23 inhibitors may give patients the best chance of achieving PASI90. Overall, the most effective biologics for achieving PASI90 were infliximab, risankizumab, ixekizumab and bimekizumab, and the efficacy of each was similar when compared with each other. The authors of this review noted that, when taking into account the balance of efficacy and safety profile, risankizumab and bimekizumab appeared to perform the best.5
With all this in mind, Dr. Fernandez provided his personal opinion in terms of the treatment algorithm for managing patients with moderate to severe psoriasis who have no comorbid conditions, including no psoriatic arthritis. For these patients, he would typically use IL-23 inhibitors as first-line agents, followed by IL-17 inhibitors, IL-12/23 inhibitors and TNF-α inhibitors. He noted that, with IL-17 inhibitors, clinicians must be cautious of the increased risk for new-onset or flare of inflammatory bowel disease.
