Over the past decade, the landscape of psoriasis and psoriatic arthritis management has undergone rapid change, with exciting treatment options becoming available over the past few years and even more treatments in late-stage development. Data presented at the Maui Derm Hawaii 2024 meeting provided insight into future directions.

Following these presentations, featured expert Steven R. Feldman, MD, PhD, was interviewed by Conference Reporter Medical Writer Rick Davis. Dr Feldman’s clinical perspectives on this topic are presented here.

When I first started treating patients with psoriasis, our primary options for managing moderate to severe disease were methotrexate and cyclosporine, and we also had acitretin and phototherapy. However, we still had a lot of patients who were suffering despite the treatment options that were available. We did our best, but we struggled to effectively help our patients. When the first biologics became available for psoriasis (ie, alefacept and efalizumab), they seemed to have good safety profiles compared with methotrexate and cyclosporine, but they were not remarkably more effective in most patients.

Then etanercept came out, and the efficacy was very impressive. I remember patients saying, “This drug has changed my life. I didn’t know how sick I was. I didn’t realize how much fatigue I had. Now I can play with my kids.” I did not think that I would see another treatment advance like that in my career, but then adalimumab came out, followed by ustekinumab, then the IL-17 inhibitors, and then the IL-23 inhibitors, each representing a quantum leap in psoriasis treatment. More recently, bimekizumab injections have become available, which seem to be even more effective for the skin and may also represent another leap forward in efficacy for patients with psoriatic arthritis. It is an exciting time to be treating patients with psoriasis and psoriatic arthritis.

When I am choosing a first biologic for a patient, I tend to start with an IL-23 inhibitor. These drugs are very effective and safe, and, in many patients, they are also effective for joint disease. And if they are not, we can then switch to another treatment option. Some practitioners may choose to start with a TNF or an IL-17 inhibitor when a patient with psoriasis also has joint involvement because they want to use an agent that is US Food and Drug Administration (FDA) approved for the prevention of joint progression. However, because many patients with psoriasis do not have joint destruction, I believe that IL-23 inhibition is generally an appropriate way to start. But again, others might decide to start with an IL-17 inhibitor in a patient with significant joint symptoms. In general, we use TNF inhibitors much less often than we used to because the IL-17 inhibitors are also FDA approved for the prevention of joint progression and generally have better safety and efficacy than TNF inhibitors.

Another major consideration is how fast the patient wants to get better. I like to explain the options to my patients and let them make the decision. While I might be more inclined to choose an IL-23 inhibitor as a first-line drug, if I have a patient who wants to get better fast and is willing to accept the possibility of associated adverse events, we will likely decide on an IL-17 inhibitor. Also, if the patient wants to try a pill first before moving to an injectable therapy, we can consider medications such as apremilast or deucravacitinib.

At Maui Derm Hawaii 2024, Gottlieb et al presented data on the efficacy of deucravacitinib on psoriasis in patients with active psoriatic arthritis. Based on previous psoriasis studies, we would expect this drug to be effective in patients who have both psoriasis and psoriatic arthritis, and this was demonstrated in this study. It is important to note, however, that deucravacitinib is not FDA approved for the treatment of psoriatic arthritis, but I think that it is a very reasonable choice for a patient with psoriasis who is also experiencing joint pain.

A poster from Gordon et al reported data on the anti–IL-36 monoclonal antibody spesolimab in the treatment of generalized pustular psoriasis (GPP). This is a fascinating development in psoriasis management. Generally speaking, we think of psoriasis as a disease of the IL-23 and IL-17 pathways. Presumably, gene alleles that are associated with activity in these pathways cause psoriasis. GPP can be due to a genetic defect in the IL-36 pathway. It may be a completely different disease, mediated by a completely different pathway, than psoriasis. It is extremely interesting and incredibly rare, and it is impressive that the investigators were able to enroll enough patients to conduct a controlled study for drug approval. Spesolimab is currently FDA approved for the intermittent treatment of GPP flares. Spesolimab led to sustained disease remission when people used the drug long-term. So, in addition to using spesolimab to treat GPP flares once patients have them, these data provide some evidence that we can prevent those flares from happening if we keep people on the drug.