A review by Rusiñol et al. emphasized the significant impact of biologicals on psoriasis management. Anti-IL-17 and anti-IL-23 biologicals are regarded as highly effective and long-lasting treatments in real-world scenarios, with IL-23-targeting biologicals showing the best safety profile and potential to modify the natural course of psoriasis.
Significant advances in psoriasis treatment have taken place since the introduction of biologicals. Tumor necrosis factor inhibitors were the first class of biologics approved, significantly improving psoriasis treatment. However, newer biologicals, directed to interleukin (IL)-23/IL-17 pathways, which play a major role in psoriasis pathogenesis, have achieved complete or nearly complete clearance rates, and are characterized by an excellent safety profile. These novel biologicals have elevated therapeutic standards, becoming an alternative for some patients whose response would have been previously considered satisfactory.
As stated in the review, real-life data can provide crucial information to guide individualized treatment. However, long-term real-world studies concerning newer drugs are still scant. A better drug survival has been consistently observed for IL-23 inhibitors – especially guselkumab and risankizumab – compared to IL-17 inhibitors and ustekinumab. IL-23 antagonists may exert different effects on tissue-resident memory (TRM) cells and T-regulatory cells in contrast to secukinumab. This could facilitate extended remission durations and offer versatility in dosing intervals.
Several factors such as gender, body mass index, metabolic comorbidities, and prior biological therapies can influence drug discontinuation. Enhanced drug survival of these novel agents is correlated with their reduced immunogenic potential. On the other hand, ‘biological fatigue’, leading to loss of efficacy regardless of pharmacokinetic considerations, is known to occur but its mechanisms may defy explanation. This highlights the importance of judiciously selecting the initial biological agent for each patient, with the one most likely to attain therapeutic success being ideal, though cost-efficacy considerations frequently play a pivotal role.
According to Rusiñol et al., further research is needed to determine whether selecting a particular mechanism of action or the most potent treatment as a primary intervention could modify the natural history of the disease. For all these reasons, baseline characteristics of patients should be carefully considered when comparing survival drug outcomes from different studies. There remains a need for more comprehensive information regarding the persistence of biological treatments and potential indicators of discontinuation, particularly in light of recent additions to the therapeutic armamentarium.
Conflict of interest
The authors of the research paper [1] declared that there was various conflict of interest.
For full details of the authors’ conflict of interest, see the research paper [1].
Abstracted by Lluís Rusiñol Batlle, MD, Department of dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona,Spain
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Use of biologicals in dermatology – following the agreed path or going off-piste? A brief report
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Reference
1. Rusiñol L, Carmona-Rocha E, Puig L. Durability and long-term outcomes of biologic therapies in psoriasis. Expert Rev Clin Immunol. 2023 Aug 25:1-12. doi: 10.1080/1744666X.2023.2250918. Epub ahead of print. PMID: 37610817.
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