The early treatment of plaque psoriasis with systemic biologic agents may lead to better overall disease management compared with delayed intervention. Although the current evidence is still developing, this approach holds promise for improving outcomes in patients with new-onset psoriasis.

The concept that the early treatment of psoriasis may have an impact on long-term disease outcomes comes from secondary analyses of randomized controlled trials. These analyses found that, in general, people with less long-term disease (eg, <2 years) had better responses to treatment and longer therapeutic remissions than those with longer disease duration. This fits the conceptual scientific framework that autoimmune diseases have a process of development over time and that the longer they go unfettered, the harder they are to treat due to a progressive priming of the immune system to the specific autoimmune phenomenon. This is why the general thinking is that it is better to treat patients as soon as possible after they start developing psoriatic disease.

On the flip side, although there is a difference in outcomes between the early and late treatment of psoriasis, these findings may be somewhat modest in their effect. Additionally, when we examine these secondary analyses of randomized controlled trials, we are breaking the randomization, and we do not know whether the short disease duration or other factors are driving this effect. Some of these patients with more established disease may have already been on biologics, for example, so they have already presented as being harder to treat.

The biggest gap is that we simply do not have a good understanding of the natural history of psoriasis. When patients present with a new diagnosis of psoriasis, we do not know which individuals will go on to have progressively more severe disease vs disease that goes into remission and does not come back for many years, if ever. We have a lot to learn in terms of how best to apply this paradigm, but the overarching theme is that it is likely better to treat patients at disease onset as opposed to waiting for a long period and cycling through various treatments before getting to something that works. We want to control the disease early with effective therapies.

Traditionally, psoriasis present on a body surface area of 10% or higher was considered the cutoff for someone to be a candidate for systemic therapy. However, we now also consider factors such as special site involvement, including the scalp, face, nails, genitals, or other areas of the body that are notoriously difficult to manage topically and cause a lot of burden for patients. Or perhaps a patient has localized psoriasis, but they are failing topical therapy. Under this model, anyone with psoriasis could potentially be eligible for systemic agents if they are bothered by their disease and/or have failed topicals. For patients with psoriatic arthritis, we initiate systemic agents regardless of how bad their skin disease is. These patients could have very minimal skin disease, but many of them will need systemic agents to manage their psoriatic arthritis.

To move this field forward, we need to start conducting research at the point of care, on the front lines. We need pragmatic studies, in which someone comes in with psoriasis and—even if it is mild in terms of body surface area—they are randomized to phototherapy, pills, or biologics compared with usual care. If we did that type of research, we would better understand the best way to treat psoriasis to achieve good long-term outcomes for patients.