The treatment landscape for plaque psoriasis has undergone rapid change, with notable entries into the psoriasis treatment armamentarium within recent years and several others in late-stage development. These therapies represent new mechanisms, pathways, and delivery systems that will meaningfully broaden the spectrum of treatment.

We are currently in a golden age for the treatment of patients with plaque psoriasis. However, one of our greatest challenges as practitioners may be choosing among the litany of available treatment and delivery vehicle options to personalize our approach to address the needs of the patient, not just the disease. This has allowed for the opportunity to improve both patient adherence to therapy and patient satisfaction over time, which are very important, given the chronic nature of the disease.

Before the age of biologics, nonspecific immunosuppressants, such as methotrexate, cyclosporine, or even phototherapy, were used in patients with plaque psoriasis because those options were all that we had available. These agents came with variable levels of success, variable data because none of these were US Food and Drug Administration (FDA) approved for psoriasis, and variable safety profiles.

We have seen an exponential growth in psoriasis treatment development since the advent of biologics, a protein-based class of medications. These monoclonal antibodies target specific elements of the immune system that are often overactive in the setting of psoriasis. Over the years, the treatment targets have continued to become more focused and more relevant to psoriasis, as opposed to nonspecific inflammatory players. The availability of these more targeted agents has changed our mindset in terms of what we can expect when treating patients with plaque psoriasis.

Our treatment options continue to expand in that now we have both injectable biologic medications and oral small-molecule inhibitors, which can be helpful for patients with needle aversion. Currently, oral small-molecule inhibitors that are FDA approved for the treatment of psoriasis include PDE4 inhibitors and JAK inhibitors. Apremilast is the only oral PDE4 inhibitor that is currently approved by the FDA for the treatment of plaque psoriasis, and, while it can be effective in patients, it is sometimes limited in use by some of its adverse effects, such as stomach upset, bloating, and diarrhea.

The category of JAK inhibitors has also been expanding in the area of plaque psoriasis. These are unique agents that target and block cytokine signaling mediated by the JAK/STAT pathway. Through that inhibition, they also inhibit communication from the outside of the cell to the inside of the cell. In turn, that can regulate the immune response, including the production of proinflammatory signals and potentially even cell growth.

There are 4 JAK family members: JAK1, JAK2, JAK3, and TYK2. How these targets are affected during treatment will dictate whether their impact occurs at the level of the immune system or other biological systems, such as platelet development or lipid metabolism. This is important to note because it can impact both efficacy and safety. These inhibitors have been used in rheumatology for some time, but now they have begun to enter the dermatology space. Tofacitinib and upadacitinib are 2 JAK inhibitors that are FDA approved for use in psoriatic arthritis, while deucravacitinib is an allosteric TYK2 inhibitor that was recently approved for use in patients with plaque psoriasis.

Thinking simply, precision, or pathophysiology-specific, medicine has the potential for better efficacy and a cleaner safety profile vs broad or widespread mechanistic approaches and resulting off-target or bystander effects. Our therapeutic approach should be biologically thoughtful. These recent developments are promising as we continue to develop holistic, individualized treatment plans for our patients.