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

Abstract and Introduction


The emergence of data from clinical trials of biologics, the approval of new biologics, and our improved understanding of psoriasis pathogenesis have increased the therapeutic possibilities for the treatment of moderate-to-severe psoriasis. Biologics currently approved for the treatment of psoriasis include tumor necrosis factor inhibitors, interleukin (IL)-17 inhibitors, ustekinumab (an IL-12/23 inhibitor), and IL-23 inhibitors. Data from clinical trials and studies of the safety and efficacy of biologics provide essential information for the personalization of patient care. We discuss the benefits and disadvantages of biologics as a first-line treatment choice, update treatment recommendations according to current evidence, and propose psoriasis treatment algorithms. Our discussion includes the following comorbid conditions: psoriatic arthritis, multiple sclerosis, congestive heart failure, inflammatory bowel disease, hepatitis B, nonmelanoma skin cancer, lymphoma, and latent tuberculosis. We make evidence-based treatment recommendations for special populations, including pediatric patients, patients with coronavirus 2019 (COVID-19), and pregnant and breastfeeding patients with psoriasis. Ultimately, individualized recommendations that consider patient preferences, disease severity, comorbid conditions, and additional risk factors should be offered to patients and updated as new trial data emerges.


Psoriasis is a chronic condition with several systemic and immune manifestations that affects more than 125 million people worldwide.[1–3] Studies have shown associations between psoriasis and other conditions, including psoriatic arthritis (PsA), multiple sclerosis (MS), congestive heart failure (CHF), inflammatory bowel disease (IBD), malignancy, and mood disorders.[2,4,5] Several effective psoriasis treatments have emerged within the last decade.[6] Approved biologics for the treatment of moderate-to-severe psoriasis include tumor necrosis factor inhibitors (TNFi: infliximab, etanercept, adalimumab, certolizumab pegol), interleukin (IL)-17 inhibitors (secukinumab, ixekizumab, brodalumab), an IL-12/23 inhibitor (ustekinumab), and IL-23p19 inhibitors (guselkumab, tildrakizumab, risankizumab).[4,5] Moreover, several biologics (e.g., bimekizumab and mirikizumab) and small-molecule therapies (deucravacitinib) are in development, complicating treatment decisions. We aim to provide an update of the evidence-based treatment recommendations for individuals with psoriasis.