Poole Dermatology

Biologics for Psoriasis

Biologic Medications for Psoriasis

Health Tips from Poole Dermatology

Psoriasis Treatments: Biologics

by Jeffrey C. Poole, MD

Biologics are the most recent advances in the treatment of psoriasis, though they have been in use in the U.S. for nearly 14 years. Biologics were initially considered 2nd line agents, but can now be considered 1st line therapy for severe, diffuse or resistant cases of psoriasis.

These drugs include such tongue-twisting names as infliximab, etanercept, adalimumab, and ustekinumab.

Biologics are often easy to use and offer dosing regimens that range from twice a week to once every 3 months. They also appear to be very safe, with minimal lab monitoring, and low side-effect profile.

Biologics should be considered when someone has psoriasis that is limiting their daily life in terms of function or psychosocially. Some examples of this include the following:

When psoriasis covers large areas of the body so that applying a topical medication to all of the affected areas is impractical. In such cases, using a "whole body" therapy, such as biologics, might be considered.

When psoriasis is especially severe, even if the affected area is limited. Examples include severe/resistant hand psoriasis in a surgeon or pianist, facial psoriasis in an actress or newscaster, or foot psoriasis in an athlete.

Psoriasis that requires "whole body" therapy, but has failed other, non-biologic treatments, such as UV phototherapy, methotrexate, and acitretin to name a few.

Each case of psoriasis has unique characteristics and each individual has a unique health history and lifestyle. These variables may make one medication a better fit for a particular patient than another.

In general, make sure you consult with a board-certified dermatologist who is experienced with treatment of complicated psoriasis.

In general, I tend to prescribe etanercept (Enbrel®) and adalimumab (Humira®) as my first agents -- both have a long track record of safety with excellent effectiveness, and are quite similar in their mode of action.

Ustekinumab (Stelara®) is the newer kid on the block, and for this reason, I generally reserve it if someones fails or does not respond sufficiently to my first options. Because Stelara® works by a different mechanism of action, there are some patients in which it may be my first line agent. Infliximab (Remicade®), while probably the most potent, also has a higher side-effect profile and requires an IV infusion, so I reserve this for my most resistant patients.

"Biologics" are a class of medications that have become an important treatment option for psoriasis.

Biologics work by targeting the underlying cause of psoriasis - excessive skin cell growth due to an overactive immune system. Although they can often provide long periods of clear skin, biologics are not a cure for psoriasis and ongoing treatment remains necessary.

Biologics are different from traditional medications because they target specific parts of the immune system rather than impacting the entire immune system. For instance, some of the biologics block a type of immune cell called a T-cell, and other block chemical signals, such as Tumor Necrosis Factor-alpha (TNF-alpha), Interleukin 17-A, or Interleukins 12 and 23.

A biologic medication may be prescribed for a person whose psoriasis is:

  1. moderate to severe
  2. cannot be controlled effectively with other psoriasis treatments, or
  3. cannot tolerate the side effects of other psoriasis medications.

In the last decade, the U.S. FDA has approved several biologics for the treatment of psoriasisand psoriatic arthritis, including:

  • Adalimumab (Humira)
  • Brodalumab (Siliq)
  • Etanercept (Enbrel)
  • Guselkumab (Tremfya)
  • Infliximab (Remicade)
  • Ixekizumab (Taltz)
  • Secukinumab (Cosentyx)
  • Ustekinumab (Stelara)

Biosimilar substitution

The National Psoriasis Foundation Medical Board has issued a statement on biosimilar substitution. Read the statement.

Categories of Biologic Medications

Tumor necrosis factor-alpha (TNF-alpha) blockers

These are drugs that block TNF-alpha. TNF-alpha is a cytokine, or a protein, that prompts the body to create inflammation. In psoriasis and psoriatic arthritis, there is excess production of TNF-alpha in the skin or joints. That leads to the rapid growth of skin cells and/or damage to joint tissue. Blocking TNF-alpha production helps stop the inflammatory cycle of psoriatic disease.

Interleukin 12/23

ustekinumab works by selectively targeting the proteins, or cytokines, interleukin-12 (IL-12) and interleukin 23 (IL-23). Interleukins-12/23 are associated with psoriatic inflammation.

Interleukin 17-A

Secukinumab and Ixekizumab bind to and inhibits a cytokine, or protein, called interleukin-17A (IL-17A), which is involved in inflammatory and immune responses. There are elevated levels of IL-17A in psoriatic plaques. By inhibiting cytokines that trigger inflammation, these drugs interrupt the inflammatory cycle of psoriasis. This can lead to improvement in symptoms for many people who take it.

Other Biologics

There are presently are several biologic medications in development.

Risks of Biologic Medications for Psoriasis

Talk with your doctor about the possible short-term and long-term side effects associated with biologics. Your doctor can help you weigh the risks and benefits of this treatment option.

Common side effects for biologics include:

  • respiratory infections
  • flu-like symptoms
  • redness and swelling at the injection site

Biologics can increase the risk of infection. Individuals who develop any sign of an infection such as a fever, cough or flu-like symptoms or have any cuts or open sores should contact their doctor right away. A biologic medication may not be recommended if your immune system is significantly compromised, or you have an active infection.

Screening for tuberculosis (TB) or other infectious diseases is often required before starting treatment with biologics. 

Do not take biologics if:

  • Your immune system is significantly compromised;
  • You have an active infection.

Using Biologic with Other Psoriasis Treatments

All the current biologics can be used with other treatments such as phototherapy or topicals, though using phototherapy along with Remicade may increase skin cancer risk.

Cimzia, Enbrel, Humira and Remicade are shown to be safe and effective when taken with methotrexate. Talk to your doctor about whether using any other treatments with a biologic is right for you.

Insurance Coverage and Reimbursement

Biologics prescribed for the treatment of psoriasis are not always covered by health insurance. It is important to check with your health insurance carrier to see if and how biologics are covered. Some insurance companies offer partial coverage, require prior authorization, or work only with certain pharmacies through mail-order programs.

Also, some biologics manufacturers provide information on how to work with insurance companies and offer reduced-cost medication for qualifying patients.