Rapid Remission of Plaque Psoriasis With Bimekizumab: A Case Discussion

In this episode of Topical Conversations, Naiem Issa, MD, and Christopher Bunick, MD, discuss their publication in the Journal of Drugs in Dermatology that highlighted a remarkable case of rapid plaque psoriasis clearance with bimekizumab. They explore the patient case, the mechanism of action driving the rapid response, key clinical insights, and future applications of bimekizumab in psoriatic arthritis (PsA) and hidradenitis suppurativa (HS). 

Rapid clearance in a treatment-naïve patient 

Dr Issa describes a male patient in his 30s with over 50% body surface area involvement who had classic plaque psoriasis but had been treatment-naïve for several years after moving to the US. After starting bimekizumab, the patient returned 3 days later, reporting rapid improvement, with plaques melting away and pruritus significantly improved within 24 hours. 

By 72 hours, 90% of his body had cleared, and within a week, his skin was completely clear, with no residual itching. Dr Issa notes that such rapid improvement is rare with biologic therapies and highlights the potential for bimekizumab to dramatically alter disease progression and patient quality of life. 

Dr Bunick emphasizes the underrecognized burden of itch in psoriasis, often associated more with atopic dermatitis than psoriasis, reflecting that bimekizumab’s efficacy in reducing both plaques and pruritus so quickly suggests it is a powerful option for improving patient outcomes. 

Why does bimekizumab work so quickly? 

Dr Bunick attributes bimekizumab’s rapid and sustained clearance to its unique mechanism of action. Unlike other IL-17 inhibitors, bimekizumab targets both IL-17A and IL-17F. While IL-17A is more potent, IL-17F is more abundant in psoriatic plaques, and inhibiting both cytokines leads to a stronger anti-inflammatory effect. 

Dr Issa highlights head-to-head trials comparing bimekizumab to adalimumab, ustekinumab, and secukinumab, all of which demonstrated bimekizumab’s superior response rates at 4 weeks. Additionally, IL-17F inhibition has been linked to rapid transcriptional changes in psoriasis plaques, supporting the observed early clearance seen in clinical practice. 

This challenges the traditional dogma that skin takes time to recover after inflammation subsides. Dr Bunick suggests that some patients may be capable of achieving near-immediate clearance, a paradigm shift in how dermatologists approach biologic response timelines. 

Addressing safety concerns 

Mood and suicidal ideation and behavior 

While bimekizumab’s prescribing information includes a warning for suicidal ideation and behavior, Dr Issa notes that in pivotal trials, Patient Health Questionnaire-9 scores, which assess the degree of depression severity, tended to improve in patients treated with bimekizumab compared to placebo. 

Dr Bunick compares this to oral isotretinoin, where concerns about depression often contrast with real-world improvements in patient mood and quality of life. As psoriasis improves, sleep, confidence, and social interactions also improve, often leading to better overall mental well-being. 

Oral and corporal candidiasis 

Candidiasis is the most common side effect associated with IL-17 inhibitors, but Dr Issa reassures that it is manageable with fluconazole or topical ketoconazole and rarely leads to treatment discontinuation. 

Dr Bunick explains that oral candidiasis tends to occur once or twice in early treatment but does not persist in most patients. However, if candidiasis is recurrent, alternative treatments may be considered. 

Expanding beyond psoriasis: bimekizumab in PsA and HS 

With additional FDA approvals for PsA and HS, bimekizumab is positioned to expand its role in dermatology. 

Dr Issa highlights that IL-17A and IL-17F levels are significantly elevated in HS, making bimekizumab a logical therapeutic option. 

For PsA, Dr Bunick emphasizes the importance of dermatologists "owning" psoriatic arthritis—as experts in skin disease, dermatologists should be actively involved in joint disease management as well. Bimekizumab’s efficacy in both psoriasis and PsA provides an opportunity to optimize care for patients with both skin and joint involvement. 

Positioning bimekizumab in the treatment landscape 

With IL-23 inhibitors already used for PsA, dermatologists may be wondering how bimekizumab should be positioned within the treatment landscape. 

Dr Bunick points to the ongoing BE BOLD trial, a direct head-to-head comparison of bimekizumab vs risankizumab in PsA, which will provide valuable insights into IL-17 vs IL-23 inhibition in psoriatic arthritis. 

Key takeaways 

• In a case study, bimekizumab demonstrated rapid plaque clearance, with a treatment-naïve patient achieving full clearance within a week
• Its dual inhibition of IL-17A and IL-17F differentiates bimekizumab from other IL-17 inhibitors
• Safety concerns such as suicidal ideation and behavior and candidiasis are manageable, with mood improvements observed in clinical trials
• Bimekizumab is now approved for PsA and HS, making it a promising option beyond psoriasis
• A head-to-head trial with an IL-23 inhibitor (BE BOLD trial) will provide critical insights for PsA management