What biologic medications, such as adalimumab (Humira) or etanercept (Enbrel), are recommended for a patient with moderate to severe psoriasis?

Biologic Medications for Moderate to Severe Psoriasis

For moderate to severe plaque psoriasis (PASI ≥10 and DLQI >10), adalimumab is the preferred first-line biologic, dosed at 80 mg subcutaneously on Day 1, followed by 40 mg at Week 1, then 40 mg every 2 weeks thereafter. 1, 2

Patient Selection Criteria

Biologic therapy is indicated when patients meet all of the following criteria: 1, 2

• PASI ≥10 AND DLQI >10 (severe disease with significant quality of life impairment)
• Failed, have contraindications to, or are intolerant of at least one conventional systemic therapy (methotrexate, cyclosporine, or PUVA)
• For psoriatic arthritis of any severity, biologics are indicated regardless of skin disease extent 1, 2

First-Line Biologic Selection Algorithm

Preferred Option: Adalimumab

Adalimumab achieves PASI 75 in 71% of patients at week 16 (versus 7% with placebo) and PASI 90 in 45% of patients. 1, 2

Dosing regimen: 1, 3

• Day 1: 80 mg subcutaneous
• Week 1: 40 mg subcutaneous
• Maintenance: 40 mg every 2 weeks
• Some patients require dose escalation to 40 mg weekly for better disease control 1

Assessment timepoint: Evaluate treatment response at 16 weeks 1, 2

Alternative Option: Infliximab

Infliximab achieves PASI 75 in 80% of patients but requires intravenous administration and mandatory addition of methotrexate to reduce immunogenicity and prevent antibody formation. 2, 4

Dosing regimen: 1

• 5 mg/kg IV at weeks 0,2,6, then every 8 weeks
• Never extend intervals beyond 8 weeks 2

Assessment timepoint: Evaluate at 10-14 weeks 1, 2

Alternative Option: Etanercept

Etanercept achieves PASI 75 in 48-66% at week 12, with slower onset of action than monoclonal antibodies. 1, 2

Dosing regimen: 1

• Initial: 50 mg subcutaneous twice weekly for 12 weeks
• Maintenance: 50 mg once weekly (some patients require 50 mg twice weekly for better control)

Assessment timepoint: Evaluate at 12 weeks 1, 2

Site-Specific and Special Indications

Adalimumab is strongly recommended (Strength A) for: 1, 2

• Palmoplantar psoriasis (30.6% achieved clear/almost clear vs. 4.3% placebo at week 16)
• Nail psoriasis
• Psoriatic arthritis (treats both skin and joint symptoms, inhibits radiographic joint damage)

Etanercept is also recommended (Strength A) for: 1

• Nail psoriasis
• Scalp psoriasis

Adalimumab can be used (Strength B) for: 1

• Scalp psoriasis
• Pustular or erythrodermic psoriasis

Combination Therapy to Augment Efficacy

When monotherapy is insufficient, add the following combinations in this order of preference: 1, 2, 4

First Choice: Topical Corticosteroids ± Vitamin D Analogues

• With etanercept: High-potency corticosteroids ± vitamin D analogues (Strength A) 1, 2
• With adalimumab: High-potency corticosteroids ± vitamin D analogues (Strength B) 1, 2

Second Choice: Methotrexate

• Recommended with etanercept, adalimumab, and infliximab (Strength B) to reduce immunogenicity and prevent antibody formation 1, 2, 4
• Mandatory with infliximab to prevent antibody formation 2, 4

Third Choice: Acitretin

• May be combined with adalimumab (Strength C) or etanercept (Strength B) to augment efficacy 1, 4
• Allows dose reduction of etanercept while maintaining efficacy 4

Other Options:

• Narrowband UV phototherapy may be combined with etanercept or adalimumab (Strength B) 1
• Cyclosporine (short-term only) may be combined with etanercept or adalimumab (Strength C) to control flares 1, 4

Assessment of Treatment Response

Treatment success is defined as: 1

• Achieving PASI 75 (75% improvement), OR
• Achieving PASI 50 (50% improvement) AND DLQI improvement >5 points

If treatment fails at the designated assessment timepoint, switch to an alternative biologic. 1

Critical Safety Considerations

Before initiating any biologic: 3

• Screen for tuberculosis (TB) and other infections
• Monitor closely for signs/symptoms of infection during and after treatment
• Be aware of increased risk of lymphoma and other malignancies, particularly hepatosplenic T-cell lymphoma in young males receiving concomitant azathioprine or 6-mercaptopurine 3

Safety profile comparison: 5

• Ustekinumab has the safest profile overall
• Infliximab shows higher rates of asymptomatic liver enzyme elevation, fatigue, and infections
• Adalimumab shows higher rates of musculoskeletal disorders and infections of all types

Common Pitfalls to Avoid

Never use systemic corticosteroids (prednisone) for psoriasis due to poor long-term efficacy and risk of severe rebound flares upon discontinuation. 2, 6

Do not delay biologics in patients with >5% BSA involvement—topicals alone are insufficient, and biologics have a high benefit-to-risk ratio. 2, 6

Do not extend infliximab dosing intervals beyond 8 weeks, as this reduces efficacy and increases immunogenicity. 2

Always add methotrexate to infliximab to prevent antibody formation and maintain drug efficacy. 2, 4