When Is a Biologic Right for Psoriasis?

By Allison C. Billi, MD, PhD, as told to Jodi Helmer

For the 7.5 million Americans diagnosed with psoriasis, it can be disheartening to hear that there’s no cure. But there are several treatments that can help keep this autoimmune disease under control.

Your dermatologist may prescribe skin (topical) creams, ultraviolet light therapy, or oral medications to treat symptoms like:

• Itchy, red patches of skin that can crack or bleed
• Silver-colored plaques
• Thick, pitted nails

But sometimes, these front-line treatments aren’t enough to treat moderate to severe psoriasis. If that happens, your doctor may recommend a biologic to get your symptoms under control.

What Are Biologics?

The traditional drugs doctors use to treat psoriasis are chemicals, and they’re created using a series of chemical reactions. Many of these medications work by calming down your entire immune system to reduce the inflammation that causes psoriasis symptoms.

Biologics are more complex medications made from natural sources that can include sugars, proteins, human or animal DNA, or even cells or tissues. They’re generally designed to target very specific parts of your immune system.

How Do Biologics Work?

Your immune system protects your body against threats like infection and cancer by mounting an attack. This presents as inflammation. When certain parts of your immune system are too active, you can get autoimmune diseases like psoriasis.

To defend against a wide range of threats, your immune system can activate many kinds of attacks by using different molecular signals. (These signals are the way your cells “talk” to each other.)

Biologics block the effects of specific molecular signals that help cause the inflammation of psoriasis, like:

• Tumor necrosis factor-alpha (TNF-alpha)
• Interleukin 17
• Interleukins 12 and 23

So they’re better at hitting the disease-causing target and easing symptoms without affecting your whole immune system.

The FDA approved the first biologic drugs to treat psoriasis in 2003. There are now 11 FDA-approved biologics for psoriasis.

Choosing the right biologic medication has been called “an art and a science” because different biologics are recommended for different scenarios. Some are more effective for children or older or obese patients. Others are better at treating psoriasis in certain areas, like the genitals.

Your doctor may try different biologics before finding the one that works best for your psoriasis.

You get these prescription drugs as injections or as intravenous (IV) infusions. You’ll need to go to your doctor’s office or an infusion center to get infusions, or learn how to give yourself injections at home. You may get treatments as often as twice a week or as seldom as once every 3 months, depending on which medication you use.

Who Should Take Biologics?

Doctors often prescribe biologics only after other psoriasis treatment options fail. In one study, researchers found that biologics were the first treatment option for fewer than 3% percent of people with psoriasis. Most tried oral medications, topical treatments, or ultraviolet light therapies first. Your insurance company may require you to try other treatments before they authorize a prescription for biologics.

Because biologics make it harder for your body to fight off infections, your doctor will recommend screening tests, including bloodwork and tuberculosis testing, before prescribing one of these drugs. Some dermatologists also check your lab work every 6 months to look for any changes.

While some biologics appear to be safe for women who are or plan to get pregnant, doctors don’t have enough information on others to say whether their benefits outweigh the risks.

If you have a history of repeated or chronic infections, cancer, or certain other diseases, your doctor may consult with your specialist when deciding whether to prescribe biologics. They want to make sure that giving you a medication that suppresses your immune system won’t make your other condition or conditions worse.

What Are the Risks of Biologics?

Biologics are safe and effective medicines. But they have a few common side effects, including flu-like symptoms, headaches, and skin reactions where the medicine is injected.

Infection is the biggest risk with taking biologic medications — and those risks are higher for those who have diabetes or smoke. Biologics suppress your immune system, increasing your risk of upper respiratory tract and urinary tract infections.

Early in the pandemic, many doctors were concerned that biologics could leave their patients more vulnerable both to respiratory illnesses like COVID-19 and to the bacterial infections that are common with serious cases of the virus. Now that we have more information about COVID-19, many dermatologists feel comfortable continuing biologics for people who already use them for psoriasis. But they might delay starting you on a biologic if you’re at high risk for severe COVID-19.

Always talk to your doctor about the risks of any medication they prescribe. Call them if you have a fever or other signs of infection while you’re taking a biologic.

Although there are some risks with biologics, research shows that these medications are effective and offer significant benefits for treating moderate to severe psoriasis.