Plaque Psoriasis


Challenging Cases in Psoriasis

conference reporter by Bruce E. Strober, MD, PhD

Psoriasis can be associated with a wide array of comorbidities, detrimental physical effects, disability, reduced psychological well-being, and impaired quality of life. A workshop on challenging cases in psoriasis was held at the Maui Derm Hawaii 2024 meeting. The discussion was moderated by Bruce E. Strober, MD, PhD, who provided further insights into this topic for Conference Reporter.


Following this presentation, featured expert Bruce E. Strober, MD, PhD, was interviewed by Conference Reporter Medical Writer Rick Davis. Dr Strober’s clinical perspectives are presented here.

"At Maui Derm Hawaii 2024, my colleagues and I presented and discussed challenging cases of patients with psoriasis and considerations for management. One question that I like to present in such discussions is: What do you do with patients who have a history of malignancy? . . . A second challenging psoriasis patient type might be a woman of childbearing potential who is trying to conceive or is pregnant."
— Bruce E. Strober, MD, PhD

At Maui Derm Hawaii 2024, my colleagues and I presented and discussed challenging cases of patients with psoriasis and considerations for management. One question that I like to present in such discussions is: What do you do with patients who have a history of malignancy? I seem to see about 1 patient per week who falls into this category. I continue to gain more and more confidence that we can use biologic therapy in those with a history of malignancy, and I feel very comfortable prescribing our modern, high-potency biologics for these patients. For example, IL-23 and IL-17 inhibitors are appropriate for patients with a history of malignancy. Apremilast is also appropriate, as are methotrexate and acitretin. Deucravacitinib, being more recently approved for psoriasis, lacks the long-term experience to give confidence in this clinical scenario. With this medication, the consideration of the drug’s risk-benefit ratio for each individual patient is important, particularly for those with a history of malignancy other than that of a successfully treated nonmelanoma skin cancer.


Based on experience from clinical trials and registry studies from around the world, we can catalog the use of the various therapeutic options in patients with a history of malignancy. The data to date suggest that the use of biologic therapy does not increase the risk of malignancy recurrence in a person who had a prior malignancy. It is, of course, important to note that malignancies sometimes do recur; however, as I say to my patients, “Using this drug will not increase the likelihood of recurrence.” I have these discussions with patients with their families present to make sure that they understand the following concept: the data do not suggest that the use of drugs such as IL-23 and IL-17 inhibitors increase malignancy recurrence rates. I always still want to have agreement from the patient’s oncologist, and I find that 9 of 10 oncologists will say, “Go for it.”


These are some of my most satisfying patients to treat because they have already had a difficult experience with cancer, and now they must also deal with psoriasis. The high-potency biologics can offer a lot of benefits to these patients, and we can help to eliminate the trauma and impact of psoriasis with very effective therapies.


A second challenging psoriasis patient type might be a woman of childbearing potential who is trying to conceive or is pregnant. Again, I feel very comfortable that such individuals can be appropriate candidates for biologic therapy. TNF blockers have been long established as safe for use during pregnancy—particularly certolizumab, which does not easily cross the placenta—but any of the TNF blockers are considered safe for use in the appropriate patient. We are also seeing more and more registry data on the use of IL-23 and IL-17 inhibitors during pregnancy.


At this point in history, we know that we should avoid methotrexate, acitretin, and even the JAK inhibitors in pregnancy. Data related to apremilast are scant. Regardless, I would rather prescribe a well-tolerated, less frequently dosed biologic therapy for a woman who is pregnant or trying to become pregnant.


Interestingly, there are a few studies suggesting that at least half of women with psoriasis who become pregnant have a remission of their psoriasis during pregnancy, perhaps because of the immunosuppressive effects of pregnancy. Pregnancy actually tamps down the mother’s immune system, which may help clear her psoriasis. So, it is not unreasonable to tell a patient who is trying to become pregnant that her psoriasis might naturally improve once she conceives. That said, there are just as many women whose psoriasis does not get better during pregnancy—in some cases, their psoriasis might even get worse.


The decision on the use of biologic therapy in pregnancy is ultimately made by the patient prior to or upon discovery of pregnancy. There are some women who do not want to be on any medication at all during their pregnancy and others who feel the opposite. The latter patients feel miserable with their psoriasis, and they do not want to have psoriasis symptoms while they are pregnant. I am very comfortable with having those patients continue on a biologic. I have had many patients who have become pregnant and have stayed on biologic therapy throughout their pregnancy to delivery because they are of the mindset that pregnancy is sometimes difficult on its own; they do not need a bad skin disease during an already sometimes challenging circumstance.


I should also mention that there are some studies indicating that severe psoriasis may in itself contribute to negative pregnancy outcomes and that an unchecked inflammatory state in a pregnant woman may create more risk for negative pregnancy outcomes, such as miscarriage or premature delivery. It is important to consider the implications of the inflammatory state for a pregnant woman. Likely, treating the psoriasis and keeping it clear or almost clear during pregnancy not only helps the patient feel better but also may be a better situation clinically for a healthier pregnancy outcome.


Egeberg A, Iversen L, Kimball AB, et al. Pregnancy outcomes in patients with psoriasis, psoriatic arthritis, or axial spondyloarthritis receiving ixekizumab. J Dermatolog Treat. 2022;33(5):2503-2509. doi:10.1080/09546634.2021.1976375


Geller S, Xu H, Lebwohl M, Nardone B, Lacouture ME, Kheterpal M. Malignancy risk and recurrence with psoriasis and its treatments: a concise update. Am J Clin Dermatol. 2018;19(3):363-375. doi:10.1007/s40257-017-0337-2


Mastorino L, Dapavo P, Avallone G, et al. Biologic treatment for psoriasis in cancer patients: should they still be considered forbidden? J Dermatolog Treat. 2022;33(5):2495-2502. doi:10.1080/09546634.2021.1970706


Patel S, Patel T, Kerdel FA. The risk of malignancy or progression of existing malignancy in patients with psoriasis treated with biologics: case report and review of the literature. Int J Dermatol. 2016;55(5):487-493. doi:10.1111/ijd.13129


Rademaker M, Rubel DM, Agnew K, et al. Psoriasis and cancer. An Australian/New Zealand narrative. Australas J Dermatol. 2019;60(1):12-18. doi:10.1111/ajd.12889


Rahmati S, Moameri H, Mohammadi NM, et al. Impact of maternal psoriasis on adverse maternal and neonatal outcomes: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2023;23(1):703. doi:10.1186/s12884-023-06006-5


Romanowska-Próchnicka K, Felis-Giemza A, Olesińska M, Wojdasiewicz P, Paradowska-Gorycka A, Szukiewicz D. The role of TNF-a and anti-TNF-a agents during preconception, pregnancy, and breastfeeding. Int J Mol Sci. 2021;22(6):2922. doi:10.3390/ijms22062922


Sánchez-García V, Hernández-Quiles R, de-Miguel-Balsa E, Giménez-Richarte Á, Ramos-Rincón JM, Belinchón-Romero I. Exposure to biologic therapy before and during pregnancy in patients with psoriasis: systematic review and meta-analysis. J Eur Acad Dermatol Venereol. 2023;37(10):1971-1990. doi:10.1111/jdv.19238


Strober B, Kavanaugh A, Stein-Gold L, Blauvelt A, Gelfand J. Workshop A: challenging cases in psoriasis. Workshop presented at: Maui Derm Hawaii 2024; January 22-26, 2024; Wailea, HI.



This information is brought to you by Engage Health Media and is not sponsored, endorsed, or accredited by Maui Derm Hawaii 2024.

Bruce E. Strober, MD, PhD

Clinical Professor, Department of Dermatology
Yale University School of Medicine
New Haven, CT
Central Connecticut Dermatology
Cromwell, CT