Psoriasis Treatment: When Should You Consider a Biologic?

Medically Reviewed by Stephanie S. Gardner, MD on June 21, 2023
3 min read

You have a lot of choices when it comes to treating psoriasis. You can try creams, ointments, shots, pills, light therapy, and even coal tar. But if your symptoms are severe and therapies you’ve tried haven’t given you enough relief, it may be time to check into biologics.

These are drugs that aim for the specific parts of your immune system that overreact in psoriasis. They sometimes can control your symptoms when other psoriasis treatments haven't helped.

They’re medicines made from living cells. The cells are genetically changed in the lab to make certain proteins. Unlike drugs that work on your whole immune system, biologics block only the parts that are responsible for the overgrowth of skin cells.

You have to take these drugs as a shot or an infusion through an IV. That bypasses your stomach, where acids would eat up the protein in the drugs and stop them from working.

Biologics are very good at relieving psoriasis symptoms. They’re also expensive, so your insurer might not cover them until after you've tried other treatments.

Unless your psoriasis is very severe or covers a large part of your body, your doctor might first prescribe methotrexate or another body-wide (systemic) immune drug to see if it works.

You might get switched to a biologic drug if you:

  • Tried one or more systemic treatments like methotrexate or retinoids and your symptoms didn’t get better
  • Couldn't stand the side effects from the drug you tried
  • Have a condition that makes other psoriasis drugs unsafe for you to take

Biologics aren’t for everyone. They can make you more likely to pick up infections. Your doctor will test you for tuberculosis, HIV, hepatitis, and other infections before you start on a biologic. If you're pregnant, ask your doctor whether it's safe for you. Experts don’t know exactly how it might affect an unborn baby. Rarely, people have gotten cancer after taking a biologic.

Other conditions that could make a biologic drug unsafe for you to take include:

  • Cancer
  • Heart failure
  • Liver disease
  • Multiple sclerosis


Biologics don't cure psoriasis, but they’re effective. Some people see clearer skin within a few weeks.

These drugs may be the best option if your symptoms are moderate to severe. Biologics work better than conventional drugs like acitretin (Soriatane), cyclosporine (Neoral, Sandimmune), and methotrexate. And their targeted actions can mean fewer side effects.

Some biologics work better the longer you're on them or if you pair them with another psoriasis treatment. But not everyone sees big benefits. Others can’t tolerate the side effects, which can include a skin reaction to the shot, diarrhea, and headaches.

Immune system proteins called cytokines cause the swelling and scaly skin patches you get in psoriasis. Each group of biologic drugs blocks a different cytokine.

Everyone responds differently to these medicines, but some biologics seem to tamp down psoriasis better than others. One review of studies showed that drugs that block two specific proteins -- interleukin-17 and interleukin-23 -- cleared skin better than ones that inhibit a protein called TNF-alpha.

Interleukin-17 inhibitors:

Interleukin-23 inhibitors:

  • Guselkumab (Tremfya)
  • Risankizumab-rzaa (Skyrizi)
  • Tildrakizumab (Ilumya)
  • Ustekinumab (Stelara) (Also targets interleukin-12)

Tumor necrosis factor-alpha (TNF-alpha) inhibitors:

  • Adalimumab (Humira)
  •  Adalimumab-atto (Amjevita)
  • Certolizumab pegol (Cimzia)
  • Etanercept (Enbrel)
  • Entanercept-szzs (Erlezi) 
  • Infliximab (Remicade)

Your doctor will pick a drug for you based on things like how clear you want to get your skin, if you have other medical conditions, and if you want shots or IVs. They may start you on drugs like those above, ustekinumab (Stelara) or secukinumab (Cosentyx), because of their good balance of effectiveness and safety.

If your first choice doesn’t control your symptoms, your doctor can switch you to another type of biologic.