What biologic (biological medication) treatments are available for androgenetic alopecia (hair loss) and psoriasis?

From the Guidelines

Biologics that can effectively treat both hair loss and psoriasis include TNF-alpha inhibitors like adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade), as well as IL-17 inhibitors such as secukinumab (Cosentyx) and ixekizumab (Taltz). These medications work particularly well when hair loss is caused by scalp psoriasis or alopecia areata with concurrent psoriasis.

Key Points to Consider

• Treatment typically involves regular injections - for example, adalimumab is usually administered as 40mg every other week after initial loading doses, while secukinumab requires 300mg injections weekly for five weeks followed by monthly maintenance 1.
• These biologics target specific inflammatory pathways that contribute to both conditions: TNF-alpha inhibitors block a key inflammatory cytokine, while IL-17 inhibitors target the interleukin pathway central to psoriatic inflammation.
• Treatment duration is typically long-term, requiring regular monitoring for side effects including increased infection risk, injection site reactions, and potential liver effects.
• Results may take 3-6 months to become fully apparent, and these medications should be prescribed and monitored by a dermatologist or rheumatologist experienced in biologic therapy.

Choosing the Right Biologic Therapy

• The choice of biologic therapy should be tailored to the individual patient's needs, taking into account factors such as psoriasis severity, presence of psoriatic arthritis, and comorbidities 1.
• A pathway algorithm can be used to guide the choice of biologic therapy, considering factors such as treatment failure, dose escalation, and switching to alternative biologic therapies.

Important Considerations

• Live vaccines should be avoided in infants born to mothers taking biologic therapy beyond 16 weeks’ gestation.
• Women of childbearing potential should use effective contraception and discuss conception plans with their consultant supervising their care.
• The risk of severe or unstable psoriasis if biologic therapy were stopped should be considered when making treatment decisions. According to the most recent guidelines from the British Association of Dermatologists 1, biologic therapy can be an effective treatment option for patients with psoriasis and hair loss, and should be considered on a case-by-case basis.

From the FDA Drug Label

In subjects with Crohn's disease and ulcerative colitis, population pharmacokinetic analyses did not indicate changes in ustekinumab clearance with concomitant use of corticosteroids or immunomodulators (AZA, 6-MP, or MTX); and serum ustekinumab concentrations were not impacted by concomitant use of these medications.

1. 1 Adult Plaque Psoriasis Two multicenter, randomized, double-blind, placebo-controlled trials (Ps STUDY 1 and Ps STUDY 2) enrolled a total of 1996 subjects 18 years of age and older with plaque psoriasis who had a minimum body surface area involvement of 10%, and Psoriasis Area and Severity Index (PASI) score ≥12, and who were candidates for phototherapy or systemic therapy

The results of Ps STUDY 1 and Ps STUDY 2 are presented in Table 8 below

Table 8: Clinical Outcomes at Week 12 in Adults with Plaque Psoriasis in Ps STUDY 1 and Ps STUDY 2

Ps STUDY 1Ps STUDY 2

STELARA ® STELARA ®

Placebo45 mg90 mgPlacebo45 mg90 mg

Subjects randomized255255256410409411

PASI 75 response8 (3%)171 (67%)170 (66%)15 (4%)273 (67%)311 (76%)

PGA of Cleared or Minimal10 (4%)151 (59%)156 (61%)18 (4%)277 (68%)300 (73%)

Ustekinumab (STELARA) is a biologic used for the treatment of psoriasis.

• It has been shown to be effective in achieving a 75% reduction in PASI score (PASI 75) and Physician's Global Assessment (PGA) of cleared or minimal in adult patients with plaque psoriasis.
• However, there is no information in the provided drug label that directly supports its use for hair loss.
• Therefore, ustekinumab (STELARA) may be used for the treatment of psoriasis, but its use for hair loss is not supported by the provided drug label 2.

From the Research

Biologics for Hair Loss and Psoriasis

• Biologic agents are used to treat moderate-to-severe psoriasis, including tumor necrosis factor inhibitors, ustekinumab, interleukin-17 inhibitors, and guselkumab (an interleukin-23 inhibitor) 3.
• There are 11 FDA-approved biologic options available for psoriasis, with more in development, making it essential to consider the unique merits and demerits of each agent when selecting a treatment 4.
• Biologics can be used to treat psoriasis in patients with comorbid conditions, such as psoriatic arthritis, multiple sclerosis, congestive heart failure, inflammatory bowel disease, hepatitis B, and latent tuberculosis 3.

Treatment Strategies

• A one-step, tightly controlled dose reduction strategy for adalimumab, etanercept, and ustekinumab can safely decrease biologic dosages in patients with psoriasis, with 67.2% of patients still using the lower dose after 1 year 5.
• Combining biologics with other systemic treatments, such as phototherapy, oral medications, or other biologics, can be effective for patients with psoriasis who require combination therapy 6.
• The preferred order for combining a second modality with biologics is biologic and methotrexate combination, biologic and acitretin combination, and then biologic and phototherapy combination, based on expert opinion 6.

Efficacy and Safety

• Biologics have been shown to be effective in reducing disease severity in patients with psoriasis, with some agents offering greater efficacy than others 4, 7.
• The safety of biologics in patients with psoriasis has been evaluated, with some agents having a more favorable safety profile than others 4, 7.
• There is limited data on the use of biologics for hair loss, and more research is needed to determine their efficacy and safety in this context.