Dermatology

Plaque Psoriasis

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Oral vs Biologic Therapy for the Treatment of Mild to Moderate Psoriasis

conference reporter by Linda Stein Gold, MD
Overview

While it is generally standard of care for mild to moderate psoriasis to be treated with topical therapies, there are cases in which biologics may be considered an appropriate first-line option. Studies presented at the Maui Derm Hawaii 2025 meeting evaluated the efficacy of systemic agents in patients with mild to moderate disease.

 

 

 

Following these presentations, featured expert Linda Stein Gold, MD, was interviewed by Conference Reporter Associate Editor-in-Chief Rick Davis. Dr Stein Gold’s clinical perspectives on these findings are presented here.

“The bottom line is that even localized psoriasis is very significant, especially for those who have disease in high-impact areas. We owe it to these patients—as we do to all of our patients with psoriasis—to make sure that we set our sights on getting them clear.”
— Linda Stein Gold, MD

 When we evaluate our patients with psoriasis, our first treatment decision revolves around whether a patient has psoriatic arthritis. No matter what their body surface area (BSA) is, if a patient has psoriatic arthritis, they are going to get a systemic medication. For patients who do not have psoriatic arthritis but do have extensive disease, our highly effective systemic therapies are able to get nearly all of them clear or almost clear.

 

However, patients who have localized disease can be “forgotten” as they continue to suffer through their psoriasis while cycling through topical therapies. These individuals often have psoriasis that involves high-impact areas, including the scalp, face, palm folds, genital area, and intertriginous areas. Such patients are often not getting the efficacy they need from topical therapies alone.

 

The International Psoriasis Council (IPC) recently updated its recommendations regarding patient eligibility for systemic vs topical therapy. The IPC recommends that patients with greater than 10% BSA, those with disease in high-impact sites, and those who have failed topical therapy are candidates for systemic therapy. This broadens the group of patients who can be considered for systemic therapy.

 

Apremilast was the first systemic medication available for the mild to moderate psoriasis population; it has US Food and Drug Administration (FDA) approval for use in all levels of severity. Studies of apremilast showed that it was effective in localized disease, and this is important because localized disease is not necessarily easier to treat. In fact, in many cases, it can actually be more difficult to manage.

 

Continuing with the oral treatments, the oral TYK2 inhibitor deucravacitinib targets the IL-23 pathway. There are studies currently underway looking at its efficacy in high-impact areas, including the genitals, palms, and soles in patients with low BSA percentages. So, we do have options in the oral category.

 

Some biologic agents have been studied in patients with less BSA involvement. A study we presented at Maui Derm Hawaii 2025 compared risankizumab with oral apremilast in patients with moderate disease and 10% to 15% BSA—so, not really localized disease but still much lower total BSA than we saw in the phase 3 clinical trials. Interestingly, when we compared Dermatology Life Quality Index scores across patient populations, it did not matter whether they had 12% or 24% BSA involvement. Psoriasis still had a major impact on their overall quality of life. We ultimately found that risankizumab was effective for patients with moderate disease, and it was more effective than apremilast in each of the efficacy assessments.

 

We also presented results from the SPECTREM study at Maui Derm Hawaii 2025. This study looked at guselkumab vs placebo in patients who had a BSA of 2% to 15% but who also had disease in a high-impact area, defined as the scalp, face, intertriginous areas, or genital area. Again, we found that this systemic agent was highly effective in getting the disease under control. Approximately three-quarters of patients on guselkumab became clear or almost clear, and more than half of them achieved a Psoriasis Area and Severity Index score of 90. When we considered efficacy based on BSA, the drug worked well, whether the BSA was 2% to 5%, 5% to 10%, or 10% to 15%. No new safety signals were identified in this study.

 

The bottom line is that even localized psoriasis is very significant, especially for those who have disease in high-impact areas. We owe it to these patients—as we do to all of our patients with psoriasis—to make sure that we set our sights on getting them clear. Insurance coverage can sometimes be challenging when patients do not have at least 10% BSA involvement. We are working to change that and to ensure that all patients have access to systemic therapy if it is needed.

References

Blauvelt A, Rich P, Sofen H, et al. Deucravacitinib, an oral, selective, allosteric tyrosine kinase 2 inhibitor, in scalp, nail, and palmoplantar psoriasis: subgroup analyses of the phase 3 POETYK PSO-1 and PSO-2 trials. SKIN The Journal of Cutaneous Medicine. 2022;6(6):s49. doi:10.25251/skin.6.supp.49

 

Blauvelt A, Rich P, Sofen H, et al. Deucravacitinib, an oral, selective tyrosine kinase 2 (TYK2) inhibitor, versus placebo in scalp, nail, and palmoplantar psoriasis: subset analyses of the phase 3 POETYK PSO-1 and PSO-2 trials. SKIN The Journal of Cutaneous Medicine. 2022;6(4):s41. doi:10.25251/skin.6.supp.41

 

Kingston P, Blauvelt A, Strober B, Armstrong AW. Deucravacitinib: a novel TYK2 inhibitor for the treatment of moderate-to-severe psoriasis. J Psoriasis Psoriatic Arthritis. 2023;8(4):156-165. doi:10.1177/24755303231201336

 

Okubo Y, Takahashi H, Hino R, et al. Efficacy and safety of apremilast in the treatment of patients with mild-to-moderate psoriasis in Japan: results from PROMINENT, a phase 3b, open-label, single-arm study. Dermatol Ther (Heidelb). 2022;12(6):1469-1480. doi:10.1007/s13555-022-00747-5

 

Stein Gold LF, Bagel J, Tyring SK, et al. Comparing the efficacy of risankizumab versus apremilast in achieving National Psoriasis Foundation’s treatment target goals: results from the phase 4 IMMpulse study [Ref# DV-014118]. Poster presented at: Maui Derm Hawaii 2025; January 20-24, 2025; Maui, HI.

 

Stein Gold LF, Bagel J, Tyring SK, et al. Comparison of risankizumab and apremilast for the treatment of adults with moderate plaque psoriasis eligible for systemic therapy: results from a randomized, open-label, assessor-blinded phase IV study (IMMpulse). Br J Dermatol. 2023;189(5):540-552. Published correction appears in Br J Dermatol. 2024;191(1):e1.

 

Stein Gold LF, Strober B, Armstrong AW, et al. SPECTREM: guselkumab demonstrates consistent significant clearance at week 16 across the full range of low body surface area, moderate psoriasis with special sites involvement. Abstract presented at: Maui Derm Hawaii 2025; January 20-24, 2025; Maui, HI.

 

Strober B, Zhong Y, Sima A, et al. Criteria for identifying candidates for systemic psoriasis treatment in the real world: application of the International Psoriasis Council guidelines in patients in North America. J Psoriasis Psoriatic Arthritis. Published online November 21, 2024. doi:10.1177/24755303241302070

 

 

 

This information is brought to you by Engage Health Media and is not sponsored, endorsed, or accredited by Maui Derm Hawaii 2025.

Linda Stein Gold, MD

    Director of Dermatology Clinical Research
    Henry Ford Health System
    Detroit, MI
    Division Head of Dermatology
    Henry Ford Health System
    West Bloomfield, MI
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