Pearls for Solving Problems when Treating Psoriasis: From the Experts
Dermatology experts share pearls to help when biologics alone are not enough, when obesity is a comorbidity with psoriasis, and when isotype switching derails therapy.
When biologics are not producing the desired result in a patient with psoriasis, make sure to ask yourself whether the diagnosis is accurate.
When biologics are not sufficient treatment for psoriasis, there are a number of options: •Biologic +topical •Biologic + intralesional corticosteroid injections •Biologic +oral therapy •Biologic + phototherapy
When biologics are not sufficient to treat psoriasis, consider adding an oral therapy, eg, deucravacitinib, apremilast, acitretin, methotrexate.
How to treat recalcitrant psoriasis in this patient with obesity: •35% BSA on secukinumab •Elevatedbloodpressure, HgbA1c 6.2% •Failed adulimumab, guselkumab
For a patient with recalcitrant psoriasis and obesity, the options to consider include: Switch to: •IL-23blocker? •Infliximab? •Brodalumab or Ixekizumab? •Bimekizumab? Or, consider adding methotrexate or - an antiobesity medication like tirzepatide??
Studies have shown excellent response to some biologic agents in patients with severe unresponsive psoriasis and obesity: •Risankizumab (IL-23 blocker): Mean PASI improvement (%) from baseline to week 52 in patients treated with risankizumab remained 88% to 98% •Infliximab: PASI 75 at week 10 reached by an average of 76% of participants •Brodalumab: PASI 100 in more than 50% of participants sustained at week 52 •Secukinumab followed by bimekisumab: PASI 100 reached by 80% of participants at week 48
Obesity negatively impacts psoriasis treatment with biologic agents: Obesity reduced by 25% to 30% the odds of achieving PASI 75
(OR 0.75; 95%CI 0.64 -0.88) and PASI 90 (OR, 0.70; 95%CI 0.59-0.81)
When the 48 y/o woman with severe psoriasis and obesity was treated with tirzepatide, she lost 60 lbs in 6 months and achieved PASI 100
Switching isotypes: A 50 y/o woman with psoriasis, no history of psoriatic arthritis has been treated with several agents, including 2 IL-23 inhibitors and finally transitioned to an IL-17 inhibitor
The isotype switching findings phenomenon: Patients may shift from a Th1/Th17-driven phenotype to a Th2-dominant phenotype; immune shift may manifest as eczematous dermatitis or other inflammatory skin changes.
Management of isotype switching: Mild: Treat through with topical therapies (eg, topical roflumilast) Moderate: Consider combining targeted therapies (eg, IL-17 inhibitor + dupilumab) Severe: Explore JAK inhibitors to address overlapping pathways
Wisdom and therapeutic advice in psoriasis was a team presentation by April W. Armstrong, MD, MPH, Mark Lebwohl, MD, Joseph F. Merola, MD, MMSc, and Ron Vender, MD that focused on strategies to aid treatment when biologics alone are not enough to achieve desired outcomes for patients psoriasis, when obesity is a comorbidity impeding treatment of psoriasis, and when isotype switching derails therapy, creating entirely new problems to deal with. The session was part of the 2025 Midwinter Clinical Hawaii Dermatology Conference, held February 15-29, 2025, on the Big Island, Waikoloa Village, HI.
