Biologic drugs seriously changed how psoriasis is treated. That’s because they affect your immune system and slow down the growth of skin cells.
"It's a dramatic improvement," says Robert Brodell, MD, FAAD, dermatology professor and chair at the University of Mississippi Medical Center. “We used to get somebody 50% to 75% better, and that was a pretty good target. Now we have drugs that are making people 90% to 100% better, and they're making them better a lot faster.”
Biologics have been life-changing for people with psoriasis, agrees Laura Ferris, MD, PhD, associate professor of dermatology at the University of Pittsburgh. "I've had patients who've had psoriasis for most of their life. They've never worn shorts in the summer. They've had limited social lives because they couldn't have clear skin. Now we have the opportunity to give these people a normal life."
There are now multiple medicines to treat moderate to severe plaque psoriasis. Different types of biologics block different proteins in your immune system. All of these proteins help your body create inflammation that can lead to psoriasis symptoms.
Some block a protein called tumor necrosis factor-alpha (TNF-alpha). They include:
- Etanercept (Enbrel)
- Infliximab (Remicade)
- Adalimumab (Humira)
- Certolizumab (Cimzia)
Others work on a protein called interleukin 17 (IL-17), including:
Still others target a protein called Interleukin 23 (IL-23). These include:
- Guselkumab (Tremfya)
- Tildrakizumab (Ilumya)
- Risankizumab-rzaa (Skyrizi)
- Ustekinumab (Stelara)
Because there aren't a lot of studies that compare biologics, it's hard to know if one works better than another, Brodell says. But he believes the newer-generation biologics may be stronger than older ones. "They're all looking at 90% and 100% clearing … and I think that's a pretty good indication that these drugs are stronger."
While most people who take biologics tolerate their treatment well and have excellent results, some biologics can raise the chances of infection or illness.
If your doctor prescribes a biologic for you, they’ll choose one based on your symptoms and any other conditions you might have.
- Some TNF-alpha inhibitors can make people who have rheumatoid arthritis more likely to get infections. They can also activate infections like tuberculous that may be sitting dormant in your body.
- If you’re taking methotrexate along with a biologic, you might be more likely to get shingles.
- The drugs that work on IL-17 could make it more likely that you’ll get a candida infection like a yeast infection.
Cost is another factor. Some of these drugs can run more than $50,000 per year. Biosimilar drugs might be an option for some people. As the name suggests, a biosimilar drug acts like a biologic, but it can cost up to 30% less.
The FDA has approved five biosimilar drugs for psoriasis:
- Adalimumab-atto (Amjevita) and adalimumab-adbm (Cyltezo) are biosimilars to adalimumab (Humira).
- Etanercept-szzs (Erelzi) is a biosimilar to etanercept (Enbrel).
- Infliximab-dyyb (Inflectra) and infliximab-abda (Renflexis) are biosimilars to infliximab (Remicade)
This treats adults with active psoriasis. It blocks an enzyme that’s linked to inflammation. Unlike biologics, which are given as shots, you take it by mouth. "Patients often prefer a pill," Ferris says. "Also, the safety profile is good, and it doesn't require lab tests." But she adds that apremilast generally doesn’t work as well as a biologic.
A recent advancement in these medications is a foam that combines a vitamin D-based drug and a steroid. The combination of calcipotriene (Calcitrene, Dovonex, Sorilux) and betamethasone dipropionate (Enstilar, Taclonex) is one of the strongest drugs for psoriasis that's not given as a shot, Brodell says. He recommends it for people with psoriasis in areas like their knees, elbows, or scalp, who don't need a drug that works throughout their bodies like a biologic does.
The foam is also good for areas where it’s hard to use creams or ointments, like your scalp. "The foams probably penetrate better through the thicker psoriasis skin. And they are more pleasing to patients because they aren't messy," Ferris says.
This has been one of the mainstays of psoriasis treatment. Ultraviolet B (UVB) therapy shines the same light rays found in sunlight on affected areas of skin.
Doctors can now use a thinner beam, called an excimer laser, on small areas of psoriasis plaques. "It lets you specifically target the light just to where the psoriasis is. It also lets you deliver a higher intensity of light," Ferris says.
Because the light is more focused, you need fewer laser phototherapy treatments than traditional phototherapy, and it does less damage to the healthy skin nearby.
New Treatments in the Pipeline
Scientists are working on a few new biologics, including ones that block inflammation in different ways. Some are being used in clinical trials where researchers test the effects of the drugs on a group of volunteers. These new drugs may keep your skin clear longer than the ones that are available now.
Researchers are also studying changes in genes that can make certain people more likely to get psoriasis. By finding the genes linked to psoriasis, scientists can learn how the immune system is affected by the disease and how that can lead to skin plaques.
Once researchers figure these things out, they can try to find out how to fix them. "There are early indications that you could take genes and splice them into people who have a defect and repair certain conditions," Brodell says. If doctors could fix the root genetic cause of psoriasis, "That could potentially be a cure."