There are many treatment options available to people with psoriasis and psoriatic arthritis. It can seem overwhelming! But it sure beats not having enough options.
Mild psoriasis is typically treated with creams, ointments, and lotions applied directly to the skin, most often with topical steroids. Mild psoriasis treatments are examined here. Those with moderate or severe psoriasis also sometimes use such topical treatments, particularly for stubborn psoriasis patches or other hard-to-treat areas.
But most moderate to severe psoriasis and psoriatic arthritis is treated with treatments that impact the whole body: ultraviolet lights directed at the skin, pills that are taken by mouth, injections made under the skin, and infusions directly into the bloodstream.
Ultraviolet Light Therapy
Like topical steroids, ultraviolet light therapy (also known as phototherapy), is a mainstay of psoriasis treatment. Ultraviolet light produces multiple effects on human cells, reducing or eliminating psoriasis patches.
For many people, simply exposing psoriasis to sunlight can improve psoriasis symptoms. Just don’t get a sunburn! That can make psoriasis worse and increase your risk of skin cancer.
There are also sources of ultraviolet (UV) light that psoriasis patients can access through a dermatologist’s office, or through home-UV light units that are often covered by health insurance.
Ultraviolet B (UVB) light has been used to treat psoriasis for more than eight decades. This original UVB is now known as broadband UVB (BB-UVB), because since the 1980’s, it has been overtaken by more targeted lights that emit only the UV rays proven to best improve psoriasis symptoms. This is known as narrowband UVB (NB-UVB).
With either UVB treatment, a patient would typically go to a medical office, and under the supervision of a nurse, stand in a private area exposing their skin with psoriasis to a bank of special, UV-emitting bulbs, for a specific duration. A typical course of treatment might be three treatments a week for five to 12 weeks – with narrowband generally clearing patients faster than broadband – with each session lasting anywhere from a couple of minutes to a half hour. Care is taken to avoid damaging (and painful) “sunburn,” which can occur with UV lightbulbs the way it can with actual sunlight. There are also seated units focused exclusively on psoriasis on the hands or feet.
UVB treatment is usually very effective, and if burns are avoided (generally by not pushing too fast to increase the dose of light of each session), UVB treatment otherwise has an excellent safety record, even for the longterm. For safety reasons, consider shielding of the face and genitals, unless your physician advises you to do otherwise.
Narrowband UVB is now the preferred method of UV light treatment, although BB-UVB remains in use as a safe and effective option as well. And notably, UVB is a good option for pregnant women, considered safe and effective during a time when women’s treatment options are more limited.
UV light treatments do pose a challenge for many psoriasis patients, since they require multiple appointments for each of several weeks, generally during business hours. Also, some insurers impose co-pay rules that can make this treatment costly. But for those who can handle the appointments, it is a tried and true treatment option.
Home UVB units are available with a prescription, and some insurers will cover them. Frequent communication with your health care provider is still needed, and patients who have problems adhering to treatment protocols might be better off avoiding the home option.
Another type of UV light that improves psoriasis is ultraviolet A. Typically, a patient would take a pill of, or take a bath in water that includes, the drug psoralen, which makes the skin more sensitive to light. Then the patient would stand before UVA lamps. This treatment regimen, known as PUVA (or bath PUVA), is generally considered slightly more effective than UVB regimens, and often leads to several months of remission.
But PUVA has fallen out of favor because it significantly increases the risk of non-melanoma skin cancers, particularly squamous cell carcinoma. There is also evidence – though disputed – that PUVA increases the risk of melanoma after extended use.
That said, the increased risk of skin cancer from PUVA has not been demonstrated in non-Caucasians, and the increased risk is disputed in bath PUVA (as opposed to pill PUVA). Still, given all the other options with greater safety and convenience now available to treat moderate to severe psoriasis, PUVA will remain a niche treatment in the US. [We should note that while Psoriasis Cure Now focuses on the US psoriasis population, PUVA is still used a good deal in some European countries.]
Psoriasis Laser Therapy
The excismer laser (XTRAC) is a high intensity UVB light that is focused directly at an individual psoriasis patch, leaving the surrounding skin untreated. While it obviously cannot be used across extensive body surface area, since it is done one patch at a time, it offers a safe and effective treatment option for stubborn or hard to treat patches. Results are seen quickly, sometimes after the first treatment, and with two treatments a week, a patch is often clear in 5-7 weeks. Remission of several months is possible after a treatment cycle.
Note that if you apply high intensity UV light to a specific patch but not the surrounding skin, when the psoriasis clears, that specific patch might then be quite tan. The tan dissipates once treatment is complete, but in the interim some people are frustrated to have traded a psoriasis patch for a different-colored patch.
Still, for those with a limited number of stubborn patches, the excimer laser or a topical steroid are both targeted, effective options to pursue with your dermatologist.
Once you move to pills, injections, or infusions, the potential for improvement in moderate to severe psoriasis increases; but safety concerns also become more of a consideration. Safety issues are addressed below, and also in this introduction to safety issues with psoriasis and psoriatic arthritis treatments.
Both old and new prescription pills are part of current psoriasis and psoriatic arthritis treatment options, with more pills winding their way through the research pipeline and potentially coming to market in the years ahead.
One of the most-used drugs in psoriasis and psoriatic arthritis is methotrexate, a drug that has been around for some 50 years. It is also used in some cancer treatment, at doses typically larger than those used for psoriasis and psoriatic arthritis. The typical methotrexate dose for psoriatic disease is between 10 mg and 25 mg weekly.
Methotrexate reins in the overactive immune response believed to cause psoriatic arthritis, and slows the over-production of skin cells that drives the creation of psoriasis patches, or “plaques.” It is taken one day a week – not daily.
Methotrexate is inexpensive and has decades of patient use behind it, but that does not mean it is without its own pitfalls and potential side effects. First, we should note that while methotrexate is US Food and Drug Administration (FDA) – approved for psoriasis, it has been used for decades also for psoriatic arthritis, although this use is technically “off-label,” which means at the doctor’s discretion. (It is so widely believed to work for psoriatic arthritis that no one has a financial incentive to do the studies necessary to get official FDA approval for that use.) It has also shown good real-world results with nail psoriasis.
Methotrexate can cause fetal death, so never use methotrexate if pregnant, or if pregnancy is a possibility.
Methotrexate can harm the liver, particularly if mixed with alcohol (or in a liver already damaged from alcohol), so most doctors urge patients not to drink alcohol while on this treatment. Blood and liver tests may be ordered periodically to make sure your liver appears undamaged. Other serious side effects are possible, so see your doctor regularly while taking methotrexate and make sure your doctor knows about all your other medications. Despite those concerns, many people have taken weekly methotrexate for decades without a problem.
(Patient to patient tip: Dermatologists and rheumatologists often differ on how much concern they have over the risks of methotrexate. You might find that your dermatologist is aggressive about closely monitoring your liver function, while your rheumatologist thinks that is overblown and unnecessary. Feel free to question both of them on what drives their concern, or lack of it, regarding methotrexate.)
Some people report stomach upset / nausea from methotrexate, particularly at higher doses. There are numerous ways to reduce this, including by dividing the once-weekly dose into three, one-third doses each 12 hours apart; by taking prescription folic acid daily (usually 1 mg per day); or by changing from pills to methotrexate by injection. Methotrexate by injection often eliminates stomach upset, and can produce the same level of improvement as pills while using less drug (thus reducing the likelihood and severity of all possible side effects). However, it can be reimbursed by insurance differently, so your out-of-pocket cost could be different.
Interestingly, a recent study found that methotrexate does not appear to work as well on psoriatic arthritis as many have long believed. That said, if the patient and doctor both are satisfied with the results, then perhaps that should be sufficient. Still, with other recent studies finding biologic therapies (injected medicines, discussed below) superior to methotrexate for both psoriasis and psoriatic arthritis, patients and doctors may soon demand the more expensive biologics for their superior performance, despite insurers preferring the inexpensive workhorse, methotrexate.
Methotrexate is also sometimes used in conjunction with other treatments, including the biologics discussed below.
Otezla (apremilast) is a recently-developed drug that is approved for both moderate to severe psoriasis and active psoriatic arthritis. It works by reducing inflammation by blocking the production of an enzyme called phosphodiesterase 4 (PDE4). It is a pill typically taken twice per day (once a day for patients with certain kidney diseases).
Otezla is an attractive treatment because it is expected to have a good long-term safety profile (and because many people prefer pills to other options). It also does not require prior TB tests or ongoing lab tests, as many other treatments do. For someone worried about the safety implications of other treatments, Otezla might be a good option. It also seems to do well on nail psoriasis.
But Otezla has downsides as well. As many as one in five new patients on Otezla have short-term side effects of diarrhea and/or nausea, which typically resolve themselves after about two to four weeks. More seriously, in some cases, Otezla can instigate or worsen depression, and suicidal thoughts or actions. While the numbers were small – in 1% or less of patients – it’s a concern that patients and their loved ones must look out for. Otezla can also cause weight loss of 5%-10% in about 10% of patients. (Some people consider this a benefit, not a negative!)
Another “ding” against Otezla may be that the improvement in symptoms is typically not as impressive as those seen with the biologic treatments (discussed below). Biologic treatments are now available that can produce 90%-100% improvement of psoriasis symptoms and 50% or even 70% improvement in psoriatic arthritis symptoms. Still, safety and convenience (and a lower price for insurers) may keep Otezla as a popular treatment for psoriatic disease.
[A final note: some dermatologists are prescribing Otezla off-label for mild to moderate psoriasis, perhaps along with a topical steroid. Psoriasis treatment strategies still combine plenty of art with the science.]
Xeljanz / Xeljanz XR (tofacitinib) is a drug that is FDA-approved for psoriatic arthritis when used along with non-biologic DMARDs (disease-modifying antirheumatic drugs, which include methotrexate and sulfasalazine). It helps to decrease pain, tenderness, and swelling in aching joints. It has also been shown in clinical trials to improve psoriasis symptoms, but as of yet, the FDA has not approved it for psoriasis (though doctors are free to prescribe it “off label” for that use). In those clinical trials it also showed positive results for nail psoriasis.
The standard dose for psoriatic arthritis is either 5 mg twice a day, or the 11 mg extended release (XR) formula once per day. While Xeljanz plus a non-biologic DMARD can begin to deliver improvement for some psoriatic arthritis patients after just a couple of weeks, in other cases it could take 3-6 months.
Compared to other non-biologics, the effectiveness of the two Xeljanz formulations is good. But biologics can deliver superior effectiveness in both psoriatic arthritis and psoriasis. So it appears the market for Xeljanz must be those who do not want to take biologics, or those who have tried and not done well on biologics.
Xeljanz also may cause serious side effects, including serious infections (some have been fatal), a higher risk of lymphoma and skin cancer, stomach issues (particularly if taken with methotrexate), and activation of Hepatitis B or C (for those carrying those viruses). Diarrhea and high blood pressure can also be issues, and investigations are examining if those with heart disease risk factors might be at increased risk of blood clots.
Given its unique method of action, Xeljanz is a welcome addition to the treatment options available for psoriatic arthritis.
Soriatane (acitretin) is a vitamin A analogue taken by pill. As a psoriasis treatment used by itself, it works less well than just about all other body-wide (“systemic”) treatments. It also has a variety of potentially serious side effects, as well as others that are merely unpleasant. But Soriatane has three arrows in its quiver that make it a useful treatment in certain cases.
First, unlike almost all the other systemic treatments, it does not suppress the immune system. This makes it an option for people with a history of chronic infection such as HIV, hepatitis B, hepatitis C, or those with cancer. Second, Soriatane can be used in combination therapy, for example with UVB (or PUVA), enhancing its effectiveness. Finally, Soriatane has shown success with pustular, palmar-plantar (hand and foot), and erythrodermic psoriasis. So Soriatane is an important treatment option to have available.
For women, the story is more problematic. Soriatane can cause devastating effects on the unborn child of a woman being treated with it. For that reason, Soriatane is generally to be avoided in women of child-bearing potential, unless there are compelling reasons to use it, and effective birth control is used throughout treatment and for three years after treatment (because the drug stays in the body for such a long time after treatment is ended).
Cyclosporine (brand names include Neoral and Sandimmune) is a drug used to suppress the immune system in transplant patients, to prevent the body from rejecting an organ transplant. It is also used to treat severe psoriasis, particularly when other treatments do not seem to work or someone is in a dangerous psoriasis flare.
Cyclosporine comes with many potentially serious side effects, limiting its use. The best way to use cyclosporine is in short courses of several weeks. Kidney damage is almost assured once the drug has been used in aggregate for about two years. High blood pressure is also a concern.
It is good to have cyclosporine as an option, if nothing else seems to work, or if psoriasis is seemingly out of control and serious immune suppression seems like the only answer. But there are simply too many other treatment options with better safety profiles and equal or better effectiveness now available for psoriasis patients in most cases. Still, cyclosporine remains a vital drug worldwide, for a variety of uses, and is one of the 300 most-prescribed drugs.
Biologics – Injectables & Infusions
Biologics are a type of medication made from proteins produced by living cells. They target specific pieces of the immune system that have been shown to play roles in driving psoriasis and psoriatic arthritis. By targeting a narrow slice of the immune system, they are designed to improve psoriatic disease with fewer side effects than earlier treatments that broadly suppressed the immune system.
Biologics are injected directly under the skin (typically by the patient at home) anywhere from twice a week to just once every 12 weeks; or are IV-infused directly into a vein at a medical office over the course of a few hours, once every 4-12 weeks. For many biologics, there are so-called “loading doses” – additional doses given in the first several weeks.
We focus here on the regular dosing that occurs after these initial doses. Also, when we write about self-injection, we assume some will choose to have a trusted loved one help them with it or do it for them, although self-injection quickly becomes quite easy for most patients.
Biologics have been at the heart of the revolution in the treatment of psoriasis and psoriatic arthritis over the last 20 years, a transformation that only seems to be speeding up over the last five years. Now, for the first time ever, sustained, multi-year and complete clearance of psoriasis symptoms, and stopping the progression of joint damage often caused by psoriatic arthritis, are realistic possibilities for many patients. Biologics are also showing strong success in treating difficult to treat areas like scalp and nail psoriasis.
Biologics are used to combat not just psoriatic disease, but many others, including inflammatory bowel diseases and rheumatoid arthritis. Millions of people worldwide have been treated by at least one biologic for one or more of these diseases.
Biologics are very expensive. Coverage can vary among insurers and be different for each biologic. The pharmaceutical and biotech companies that produce them are, in many cases, helping reduce the out of pocket cost for insured patients, and providing biologics free of charge to some poor, uninsured patients; but for the non-poor uninsured, the cost can simply be too high to afford. If you have been prescribed a biologic but are unable to afford it, please contact us and share your story so we can take your experiences to Congress, health insurers, and the drug companies as we work to ensure no patient is left out of this treatment revolution.
In the coming years, “biosimilars” will arrive on the scene and perhaps bring some lower prices. Biosimilars are like generics, but since biologics are generated from living organisms, the “copies” will not be exact duplicates. To secure FDA approval, biosimilars will have to prove in a clinical trial that they are not inferior to the original biologic they are trying to replicate. As biosimilars reach the U.S. psoriatic disease market, we will alert you and bring you detailed coverage of them.
Biologics can also cause, in a small percentage of cases, serious side effects, particularly in those with other significant health issues. Among the millions of users of biologics worldwide, there have even been fatalities. Serious infections are also an issue in a small but significant number of cases. But if you see your physician regularly and do all the required monitoring, including tests before you start treatment and others as treatment continues, most side effects can be managed, or you can be moved to a different treatment.
Interestingly, a 2018 study of 9,000 British psoriasis patients found no significant increased relative risk of serious infection for those treated with any of three biologics studied as compared to those treated with the non-biologic pills discussed above. The authors concluded that infection risk should not be the determining factor in choosing between biologic and non-biologic treatment options.
Another assumption has been that the way biologics target the immune system might lead to an increased risk of certain cancers. But two recent studies have suggested there is no significant increased risk of cancers following biologic treatment. One researcher was quoted saying the jury is still out on this issue, but the recent findings are more promising than had been expected.
We now have people who have been on biologics for ten and even 15 years and longer without problems. They feel great, have their psoriatic or other disease under control, and are living their best lives, no longer facing the daily physical and emotional pain from the chronic diseases that had debilitated them.
There are many things to consider when selecting a biologic (or other) treatment; you can learn more about that here. But below we break down the treatments by categories that are often used by physicians and in the scientific literature. And remember (as we wrote elsewhere on this website): in selecting a treatment option that will work for you, the good news is there is probably more than one right answer.
Biologics for psoriatic disease are typically divided into different classes, based on which pieces of the immune system they target, inhibit, or interfere with:
- TNF-alpha inhibitors
- IL-12/IL-23 inhibitor
- IL-17 inhibitors
- IL-23 inhibitors
- T-cell modulator
If a patient does not improve sufficiently on one treatment, or that treatment later loses effectiveness, many doctors will then try a treatment from a different class of biologics; however, some patients who “fail” (as it is sometimes called) on one biologic within a class may still succeed on a different therapy within the same class.
We apologize if we sound like cheerleaders. No treatment that can cause serious infections, or potentially increase cancer risk, should be taken lightly. But our assessment – remember, we are patients, NOT doctors! – is that generally speaking, the benefits of biologics outweigh the risks for most people with moderate to severe psoriatic disease. (Importantly, this is less often the case when the patient has psoriasis along with one or more other serious health issues, requiring tricky balancing of multiple treatments.) Biologics can give many of us, for the first time in history, a chance to live in a way where we can even forget we have psoriatic disease.
Here is a quick primer on the specific biologics currently available. Choosing the best fit for you is a task for you to do jointly with, and utilizing the expertise of, your dermatologist and/or rheumatologist.
These were the first biologics approved for psoriasis and psoriatic arthritis, and are still used extensively today for those and other diseases. They have long track-records of use that can give you confidence that their safety concerns are well-understood and able to be minimized.
Typically one can determine if a TNF-alpha inhibitor is likely to work for a patient or not after 12 to 16 weeks (8-10 weeks for Remicade).
Enbrel (etanercept) is a longtime blockbuster biologic approved for both psoriasis and psoriatic arthritis. While it is still used by many psoriasis patients who have been on it successfully for years, it is not prescribed often for new psoriasis patients, as there are numerous other biologics which clear the skin more effectively for more people. It is still newly-prescribed for psoriatic arthritis, however, as it does an excellent job reducing joint pain and swelling, and in blocking further joint damage from occurring.
Enbrel is also FDA-approved to treat chronic moderate to severe plaque psoriasis in children four years and older, which speaks in part to its favorable side-effect profile.
Enbrel is given by self-injection under the skin once or twice a week.
Humira (adalimumab) remains one of the most popular biologics worldwide, for psoriasis, psoriatic arthritis, and for several other diseases. It is very effective in treating psoriatic disease, and while its infection risk is a bit higher than some other biologics, its safety is well-understood from 15+ years and millions of patients treated across all the diseases it treats. Its mega-blockbuster status is not undeserved.
Humira has demonstrated capacity to be effective in psoriasis patients who have failed Enbrel, another TNF-alpha inhibitor. After 12 and 24 weeks, roughly one-third and nearly one-half respectively of those who had not done well on Enbrel went on to get clear or almost clear with Humira, suggesting that changing even to another treatment within the same class of biologic can be a successful treatment strategy. Humira has also shown success treating psoriasis of the hands and feet.
Humira is self-injected under the skin every 14 days. Some people develop auto-antibodies to Humira that can lessen its effectiveness over the course of years; others have taken it successfully for a decade or more.
Remicade (infliximab) is yet another highly-effective biologic for psoriasis, psoriatic arthritis, and other diseases. Remicade is an IV infusion that is given at a medical office, typically once every eight weeks, over the course of a couple hours. Patients are awake and read, watch TV, or play on their phones during the infusion.
Remicade, like cyclosporine, is sometimes used by patients in a crisis state with their psoriasis, because it can improve symptoms relatively quickly and can pack a punch. A recent study found that a cost of this “punch” is that those receiving Remicade treatment had an increased risk of serious infection compared to those receiving non-biologic pills discussed above.
One benefit for larger, overweight, or obese patients is that Remicade has weight-based dosing. The more you weigh, the more Remicade you receive in your infusion. This also means that lighter people get the minimum dose needed to improve their symptoms, possibly minimizing side effects for those patients.
Many other biologics use the same dose for all patients, although physicians sometimes have leeway in how they prescribe biologics: a biologic that is typically taken every 14 days, for example, might be prescribed every 12 days, to increase the average amount of biologic in a patient’s system over time. Health insurers sometimes deny coverage for these tactics.
Cimzia (certolizumab pegol) is a biologic FDA-approved for moderate to severe psoriasis and active psoriatic arthritis (among other diseases). It is injected under the skin, either by you at home or by your health care provider in a medical office.
For psoriasis, the dose is either one or two injections on the same day, every other week. This allows for weight-based dosing, with those under 200 pounds having the option of the lesser dose, and presumably a lesser chance of side effects.
For psoriatic arthritis, the standard dose is either one injection every two weeks, or two injections on the same day, every four weeks.
Cimzia has good effectiveness in both psoriasis and psoriatic arthritis, in line with the other TNF-alpha inhibitors (and in one psoriasis trial, the bigger dose of Cimzia was more effective than the standard dose of Enbrel). And while its more common side effects include manageable infections and diarrhea, there can also be a host of rare but serious side effects. Be sure to discuss potential serious side effects, and the likelihood of having any serious side effects, with your physician prior to starting Cimzia treatment.
For women who are or may become pregnant, Cimzia may be of particular interest, especially in the third trimester of pregnancy, because Cimzia does not cross the placental barrier to the unborn child. (All TNF-alpha inhibitors are believed to be safe for the fetus in the first two trimesters, although if UVB is an option during pregnancy, it is probably the safer course.)
Simponi / Simponi Aria (golimumab): Simponi is self-injected under the skin once a month. Simponi Aria is IV-infused in a medical setting every 8 weeks. (Here we’ll refer to both versions simply as “Simponi.”) Simponi is FDA-approved for psoriatic arthritis but not psoriasis, though in clinical trials, Simponi also did a good job improving the skin psoriasis of psoriatic arthritis patients (although the average amount of psoriasis at the start of the studies appeared more on the moderate than the severe side).
Simponi is often taken in combination with methotrexate or similar oral treatments. It can take from three to six months to get the full benefit of Simponi.
Simponi patients face the same set of potential side effects as those using the other TNF-alpha inhibitors, including infections and some rare but serious side effects.
IL-12 / IL-23 inhibitor
Stelara (ustekinumab) is the biologic that targets both psoriasis and psoriatic arthritis (and other diseases) by inhibiting two parts of the immune system implicated in psoriatic disease (IL-12 and IL-23). Since its FDA-approval for psoriasis in 2009 (and psoriatic arthritis in 2013), it has been a blockbuster biologic used frequently to treat psoriatic disease. Stelara has been extensively studied, and used by many patients for as long as a decade, giving physicians a strong knowledge base to prescribe it. Stelara is also FDA-approved for psoriasis patients age 12-17.
Stelara is injected under the skin by a health care practitioner in a medical office, or by self-injection at home, just once every 12 weeks, making the self-injection route one of the easiest treatment regimens available for psoriasis or psoriatic arthritis. It is also available in two dosing levels to allow for weight-based dosing, with the larger dose designed for those weighing more than 220 pounds.
Stelara provides impressive improvement of symptoms of psoriasis, although its effect on psoriatic arthritis is considered less strong than several other of the biologics. (TNF-alpha inhibitors, for example, have FDA-approved labeling indicating they can stop the progression of permanent joint damage in psoriatic arthritis. Stelara does not have that labeling.)
IL-17 inhibitors do a fantastic job clearing even severe psoriasis. After 16 weeks, two-thirds of patients can see a 90% improvement in their psoriasis symptoms, and many can achieve a 100% improvement – totally clear skin. Improvement can often begin to be seen in just a week or two. Typically one can determine if an IL-17 inhibitor is likely to work for a patient or not after 12 weeks.
They also perform well in psoriatic arthritis, although they are generally tried after TNF-alpha inhibitors for psoriatic arthritis, unless the patient also has psoriasis that is severe. But they are typically tried in psoriatic arthritis before IL-23 inhibitors (discussed below).
IL-17 inhibitors enjoy favorable safety profiles, but are not without significant risks. IL-17 inhibitors can increase your risk of infections, particularly Candida infections. In addition, they can bring about new occurrences of inflammatory bowel diseases (IBD: Crohn’s disease or ulcerative colitis), or trigger flares in existing IBD patients. Tell your healthcare provider if you develop symptoms of stomach pain or diarrhea while being treated with IL-17 inhibitors. If you or an immediate relative has IBD, you should consider starting instead on an IL-23 or TNF-alpha inhibitor for your psoriatic disease, rather than an IL-17 inhibitor.
Cosentyx (secukinumab) is generally administered for psoriasis, after loading doses, as two self-injections under the skin on one day, every 4 weeks. Some patients can instead do well with just one injection every four weeks. For psoriatic arthritis, absent significant psoriasis, the dose is typically one injection every four weeks.
In clinical trials, after 12 weeks, a majority of Cosentyx patients had achieved a 90% improvement in psoriasis symptoms, which reached as many as four in five patients after 16 weeks, besting (among others) Stelara. After one year, 76% of Cosentyx patients were still 90% improved. Safety was comparable between Cosentyx and Stelara.
In addition, after 12 weeks, about one quarter of Cosentyx patients were 100% improved: their skin was clear.
Cosentyx has also demonstrated effectiveness in nail, palmoplantar, erythrodermic, and generalized pustular psoriasis. The two-injection (300-mg) every four week dose is general recommended for these difficult psoriasis subtypes.
Taltz (ixekizumab) is taken by self-injection under the skin once every 4 weeks, both for psoriasis and for psoriatic arthritis. (Some experts note that some patients may need that dose every two weeks to maintain their treatment response. It is unclear how insurers would react to that.)
Taltz is highly effective in treating moderate to severe plaque psoriasis. At week 12, about 7 in 10 patients had a 90% improvement in psoriasis symptoms, and one-third had fully 100% improvement – clear skin. Taltz has also shown effectiveness in treating scalp, erythrodermic, nail, genital, inverse, palmoplantar (nonpustular), and generalized pustular psoriasis.
For example, in a scalp psoriasis trial, after 20 weeks, patients had an average of 75% or better improvement, and after a year, 78% had complete resolution of their scalp lesions. Similarly, after a year, half of Taltz of patients with nail psoriasis showed complete resolution of it.
In a psoriatic arthritis clinical trial, Taltz demonstrated equal effectiveness to Humira in improving pain and swelling of joints and digits, while surpassing Humira in clearing skin psoriasis. After 24 weeks, more than one-third of Taltz patients with psoriatic arthritis had achieved an impressive 50% improvement in arthritis symptoms, and about 20% had achieved a 70% improvement.
Side effects with Taltz are similar to other IL-17 inhibitors. Notably, in a 60-week clinical trial, about 12% had mostly short-term problems with their levels of a type of white blood cell; candida fungus infections occurred in about 3% of patients; and fewer than 1% developed inflammatory bowel disease.
A recent clinical study in pediatric patients ages 6-17 found the vast majority of these young Taltz patients with moderate to severe plaque psoriasis achieved a 75% improvement in their psoriasis symptoms after 12 weeks. The full data from that study, including side effects data, is expected soon.
Siliq (brodalumab) is FDA-approved for psoriasis, but not for psoriatic arthritis. It is self-injected under the skin every 2 weeks.
Siliq is highly effective in treating psoriasis. In clinical trials, at 12 weeks, 7 out of 10 patients had a 90% improvement in their psoriasis symptoms, and about 40% of patients had a 100% improvement – clear skin.
Siliq also performed well in a small psoriatic arthritis trial, achieving 50% and 70% improvement roughly as often as other IL-17 inhibitors. It has not sought FDA approval for psoriatic arthritis.
But Siliq, in addition to the usual potential side effects for IL-17 inhibitors, carries the highest FDA warning in its package labeling – a black box warning – about rare cases of suicidal ideation and completed suicides that have occurred during treatment with Siliq. As a result, Siliq can be prescribed only by approved physicians through a restricted program called a “risk evaluation and mitigation strategy.” Siliq should not be considered as a treatment option in patients with recent, or a history of, suicidal ideation, suicidal behavior, or severe depression.
IL-23 inhibitors may take longer to clear the skin than the IL-17 inhibitors, but once they achieve their potential the results are highly impressive rates of 90% and 100% improvement in psoriasis symptoms.
The IL-23 inhibitors are the newest class of psoriasis treatment to reach patients, so new that they are not yet even FDA-approved for psoriatic arthritis, as are most other psoriasis biologics. But they are already making a major splash treating moderate to severe psoriasis. And they tend to require fewer injections than other biologics for psoriatic disease.
The IL-23 inhibitors are still in clinical trials for psoriatic arthritis. Results to date are promising, but for now, expert opinion is generally that the other classes of biologics should be tried first for psoriatic arthritis before looking at the IL-23 inhibitors. We’ll see if that advice changes in the years ahead.
IL-23 inhibitors appear to have favorable safety profiles, but as these are new treatments, we simply do not have enough long-term data, or data on enough patients, to make fully-informed assessments about their potential side effects. What is known is that IL-23 inhibitors, like other biologics, lower the ability of the immune system to fight infections and will likely increase risk of infections. Also, rare cases of elevated liver enzymes have occurred with use of IL-23 inhibitors.
Tremfya (guselkumab) is FDA-approved for moderate to severe plaque psoriasis, and is taken by injection under the skin every 8 weeks. The first injection is done at the dermatologist’s office, and subsequent injections are self-administered at home.
Tremfya produces very strong results in clearing psoriasis. After 16 weeks, 70% of Tremfya patients see a 90% improvement in their psoriasis symptoms. In another trial, of those who had achieved a 90% improvement by week 16, 89% of them still maintained that 90% improvement after 48 weeks.
There are other types of data supporting Tremfya’s effectiveness. In a 48-week head-to-head trial against Cosentyx, 84% of Tremfya patients and 70% of Cosentyx patients achieved a 90% improvement in psoriasis symptoms, even though Cosentyx patients originally improved more quickly. Other studies have demonstrated that even the majority of psoriasis patients for whom Humira or Stelara prove insufficient, do better when switched to Tremfya. Finally, Tremfya has also shown effectiveness on scalp, nail, and plaque-type palmoplantar (hand and foot) psoriasis.
The most common side effects of Tremfya are infections, including contagious fungal infections of the skin, herpes simplex virus infections, and intestinal infections; diarrhea; and joint pain.
Skyrizi (risankizumab-rzaa) was FDA-approved for moderate to severe plaque psoriasis in 2019. It is given as an injection under the skin every 12 weeks, either at a physician’s office or by self-injection at home. This makes it, along with Stelara, one of the easiest psoriasis treatments available.
It is also one of the best-performing psoriasis treatments. In clinical trials, after 16 weeks, more than 7 in 10 Skyrizi patients achieve a 90% improvement in psoriasis symptoms. In another trial, two-thirds of patients who improve moderately on Humira by week 16, and are then switched to Skyrizi, achieve a 90% improvement at week 44. And in a third trial, which showed Skyrizi outperformed Stelara in clearing psoriasis; at week 12, 45% of Skyrizi patients had achieved a 100% improvement in psoriasis symptoms – clear skin.
Skyrizi appears to have a favorable safety profile, but it is worth noting that there is substantially less duration of data, and on many fewer patients, evaluating the safety of Skyrizi than most other biologics, which have had longer clinical trials and real-world use.
Ilumya (tildrakizumab-asmn) is FDA-approved for moderate to severe plaque psoriasis, and is given at a dermatologist’s office as an injection under the skin every 12 weeks.
At week 12, almost 40% of Ilumya patients have achieved a 90% improvement in their psoriasis symptoms. Now there is long-term data demonstrating that after 4 years, roughly 60% of patients have maintained a 90% improvement in psoriasis symptoms, and roughly 30% have maintained a 100% improvement – clear skin.
Ilumya appears to have a favorable side effect profile. The most common side effects with Ilumya are infections and diarrhea.
Orencia (abatacept) is FDA-approved as a treatment for active psoriatic arthritis. It is not FDA-approved for psoriasis, and its impact on psoriasis patches is merely modest.
It can be taken as a monthly IV-infusion in a medical setting, or as a weekly self-injection from home.
One scientific review of Orencia concluded its best use was “mainly for patients with peripheral joint involvement and mild psoriasis.” In one clinical trial, about 40% of psoriatic arthritis patients saw a 20% improvement in symptoms after 24 weeks. (That study, however, had a high, 22% placebo rate meeting that improvement rate as well.) Its performance on 50% improvement beat placebo by 7%, and 4% more of Orencia patients than patients on placebo achieved a 70% improvement.
In that study most of the patients had already tried a TNF-alpha inhibitor unsuccessfully, and were also on methotrexate throughout the study. (Like other biologics, Orencia can be taken together with other non-biologic DMARDs, but should not be taken at the same time as another biologic.)
As with other biologics, there is an increased risk of infection with Orencia, including risk of serious infections.
It is good to know psoriatic arthritis patients have a treatment option that works differently than the others, and so may work for them even if other treatments fail them.
There are more, and better, treatments for psoriasis and psoriatic arthritis than ever before. Finally, many or most of us can achieve levels of improvement that will allow us to go from being patients focused on treatment, to simply being people chasing our dreams.
[Last updated 5-25-2020]