Debate: Should Biologics Be Used for Milder Cases of Psoriasis?

M. Alexander Otto, PA, MMS

April 25, 2021

The remarkable efficacy of biologics for moderate-to-severe psoriasis has led some to ask if biologics should be used for milder cases.

The issue was tackled in a debate at the American Academy of Dermatology Virtual Meeting Experience (AAD VMX) 2021.

Taking the con side, Kenneth Gordon, MD, professor and chair of dermatology at the Medical College of Wisconsin, Milwaukee, argued that with the high cost of biologics, availability of many alternatives, and other issues, "we should just say no … There is no good reason that we need to expand the use of biologics in patients with limited disease."

Dr Kenneth Gordon

On the pro side, Richard Langley, MD, professor of dermatology at Dalhousie University in Halifax, Nova Scotia, Canada, argued for a nuanced approach. He noted that patients with smaller patches of disease can be just as miserable as patients who hit traditional benchmarks of increased severity, such as high body surface area involvement — especially if those small areas are in sensitive locations like the scalp, palms, or genitals.

The decision to use a biologic should hinge on how badly patients and their quality of life are affected, not on "some artificial and limiting definition" of severity, Langley said. 

Gordon didn't disagree, noting that current use criteria include objective measures as well as disease in sensitive areas and failure of alternative treatments.

Rather, he was concerned about "expanding the definition of who is eligible beyond these criteria … to chase every last bit of" disease. "I don't think we have" a good rationale for that approach, he said.

Cost is the most important issue, Gordon said.

With more biologics on the way and prices continuing to go up, "there is going to a be a huge challenge to our use of these expensive medicines over the next few years" from payers. "It is important that we use them smartly in order to make sure we are able to use them for people with severe disease" who really need them. If "we start using biologics for all our patients with psoriasis," it will be a "cost disaster," Gordon said.

In addition, topicals and home phototherapy can be effective as long as patients adhere to them, as can alternative systemic agents, such as methotrexate and apremilast.

Often with biologics, "the issue is mainly convenience" rather than a fundamental problem with the alternatives, and despite the good safety record in trials, "chasing the last bit" of psoriasis with a biologic "is not necessarily" without risk for the patient, Gordon said.

Dr Richard Langley

Still, there can be a "pretty significant disconnect" between how patients perceive their psoriasis and "what physicians are thinking and prescribing" for it based on objective measures, Langley noted. Sometimes patients who have limited disease but are in significant distress aren't even receiving treatment or are only given another cream to add to their collection of ones that haven't worked.

One problem with traditional severity classifications is that they don't generally take patients' subjective experience into account, he added. There's also been a lack of standardization to the point that dermatologists, researchers, and payers can sometimes disagree over severity in a given patient.

There's movement toward better incorporation of patient experience into severity considerations, but for now at least, a designation of mild psoriasis can underestimate the true severity of disease, Langley said. 

Dr Gordon and Dr Langley reported receiving honoraria and/or research support from many pharmaceutical companies, including AbbVie, Pfizer, and Lilly.

American Academy of Dermatology Virtual Meeting Experience (AAD VMX) 2021.

M. Alexander Otto is a physician assistant with a master's degree in medical science and a Newhouse journalism degree from Syracuse University. He is an award-winning medical journalist who worked for McClatchy and Bloomberg before joining Medscape and also an MIT Knight Science Journalism fellow. Email: aotto@mdedge.com

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