Biologic Treatment Algorithms for Moderate-to-Severe Psoriasis With Comorbid Conditions and Special Populations

A Review


Am J Clin Dermatol. 2021;22(4):425-442. 

In This Article


New RCTs, postmarketing surveillance data, and approval of additional biologic classes have increased the treatment options available for moderate-to-severe psoriasis. This review provides first-line treatment recommendations for managing psoriasis in several clinical scenarios (Table 1).

Since IL-23 inhibitors were recently approved for the treatment of psoriasis, postmarketing trials are needed to confirm their safety and efficacy. Mirikizumab, another IL-23p19 inhibitor, has yet to be approved for psoriasis treatment, but preliminary results are promising.[209,210] The RCTs OASIS-1 (n = 530) and OASIS-2 (n = 1484) compared mirikizumab with placebo and secukinumab and demonstrated superior efficacy for mirikizumab, with results sustained at week 52.[209–211] Rates of severe AEs remained < 6%.[211] Recent RCTs have also supported the efficacy of biosimilars compared with originator drugs; however, utilization in the USA has yet to gain momentum.[212–216]

A limitation of this article is the potential subjective selection bias for pivotal pertinent articles. Moreover, data from phase III RCTs may be biased because of the selective enrollment criteria. A strength is the breadth of literature included, with a large number of RCTs evaluated.

The indications and limitations of each biologic need to be carefully considered while creating a treatment protocol. As stronger evidence emerges, the treatment algorithm should be modified accordingly.