Dr Lebwohl expounded upon a common clinical question: how to choose a treatment regimen for patients with psoriasis in a world with dozens of biologics and small-molecule inhibitors. In addition to considering pertinent medical history like inflammatory bowel disease or concomitant autoimmune disorders, Dr Lebwohl looks for biologic medications with evidence to mitigate or prevent psoriatic arthritis. He presented data from numerous randomized trials that showed promising results from various TNF-alpha inhibitors and biologics alike. Etanercept inhibited structural damage of joints compared to placebo based on no change from baseline of the Sharp, or van der Heijde, score in one trial, and 45% to 58% of those on secukinumab demonstrated a 20% improvement in ACR, depending on previous TNF-inhibitor exposure, compared to 15% who were on placebo. Ustekinumab, ixekizumab, and bimekizumab demonstrated similar, if not superior, responses, suggesting that IL-17, IL-23, and IL-12/23 inhibitors share this effect. Bimekizumab in particular achieved an ACR20 in 62% of people compared to 68% on adalimumab at week 24. Guselkumab dosed every 4 weeks demonstrated significant improvement in Sharp, or van der Heijde, score, though every 8 weeks did not reach significance.
Dr Lebwohl then examined multiple trials looking at the other small-molecule inhibitors’ impact on psoriatic arthritis. He started with apremilast, the oral PDE4-inhibitor, which also showed moderate improvement in ACR scores at both doses at week 16. Known for their quick onset of action, the JAK inhibitor class also has shown benefit for psoriatic arthritis with 70% of upadacitinib users achieving ACR20 at week 12. Deucravacitinib, the TYK2 inhibitor, similarly decreased ACR scores in multiple RCTs. On the other hand, methotrexate has not been shown to prevent joint damage on x-ray. Dr Lebwohl also reported cyclosporine and acitretin as not effective in preventing joint disease.
Another variable to consider in some patients, Dr Lebwohl showed us, is weight in obese patients who haven’t achieved adequate response to medications. One trial showed that response to ixekizumab was modified by weight with 75% of those <80 kg achieving a PASI90 compared to 61% of those >100 kg achieving the same response. The difference was even greater for those receiving every-4-week dosing. Response to adalimumab can also be stratified by body weight, interestingly including the placebo group in the CHAMPION trial. For both ixekizumab and secukinumab, the higher doses were more efficacious for patients >90 kg. It appears that almost all of the biologics have evidence for weight-stratified responses. More evidence is required to determine if the same is true for the JAK inhibitor class.
In the first DermInsider - A Virtual Grand Rounds Series session of the year, join leading experts Dr. Bhutani and Dr. Serota for a dynamic deep dive into one of the most exciting frontiers in psoriatic disease management. Dr. Del Rosso moderates this 45-minute activity that explores the rapidly emerging role of glucagon-like peptide-1 receptor agonists (GLP-1RAs) and their potential impact beyond metabolic disease. Don't miss out on this opportunity to catch up on breakthrough insights and emerging evidence on this hot topic!“We have some really interesting data on the horizon that’s going to hopefully help more providers feel confident about using [GLP-1] medications in conjunction with their psoriasis medications that they are used to using.” – Tina Bhutani, MD MASBest of FC25: GLP-1RAs in Psoriasis – Catching Up on The ScienceThis activity is supported by an educational grant from Lilly.
Got a few minutes? Join our expert faculty for their rapid-fire tips on getting started with GLP-1 receptor agonists for patients with psoriasis and obesity.“When we are treating patients with obesity and psoriasis in weight management, really focus on the health gains. It’s not about what people are losing, it’s about what they are gaining in this process.” – Angela Fitch, MDPlease visit the “Educational Resources” page to access the handouts developed by faculty on GLP's in psoriatic disease mentioned in this activity.This activity is supported by an educational grant from Lilly.
In this 20-minute Seminar in Depth from the 2025 Fall Clinical Dermatology Conference, the faculty explore what differentiates TYK2 inhibitors from traditional JAK inhibitors, as well as how to identify patients with psoriasis who may benefit from oral small molecule therapy.“When thinking about a medication, you need to take a number of things into consideration: location of disease, disease severity, and age. Age plays a big role when I think about what medication I’m going to choose for a patient – Are they of child-bearing age? Are they young and they live in group housing or a dorm?” – Benjamin Lockshin, MDFC25: Encapsulating Progress With New and Emerging TYK2 Inhibitors for Psoriasis: An Online ActivityThis activity is supported by an educational grant from Bristol Myers Squibb.