What is the best biologic for a patient with inverse psoriasis?

Best Biologic for Inverse Psoriasis

For inverse psoriasis, IL-17 inhibitors (secukinumab, ixekizumab, brodalumab) are the preferred biologic class, with secukinumab being the most established option given its strong efficacy data and favorable safety profile for intertriginous areas.

Rationale for IL-17 Inhibitors in Inverse Psoriasis

IL-17 inhibitors demonstrate superior efficacy for challenging psoriasis subtypes affecting flexural and intertriginous areas 1. While inverse psoriasis treatment can be challenging due to its location in skin folds, biologics targeting the IL-17 pathway have shown particular effectiveness 1.

Secukinumab should be initiated at 300 mg subcutaneously at weeks 0,1,2,3, and 4, followed by 300 mg every 4 weeks, with 79% of patients achieving PASI 90 at week 16 2. This dosing regimen provides rapid and sustained clearance, which is critical for the moist, friction-prone areas affected by inverse psoriasis 2.

Alternative Biologic Options

IL-23 Inhibitors (Second-Line)

• Risankizumab demonstrates the highest PASI 90 scores among all biologics in both short and long-term studies, with the most favorable long-term risk-benefit profile 3
• Ustekinumab (IL-12/23 inhibitor) may be preferred in patients with history of severe infections or malignancies, as it shows no definitive evidence of increased malignancy risk 4
• IL-23 inhibitors require less frequent administration, which may improve adherence 5

TNF Inhibitors (Third-Line)

• Infliximab shows superior efficacy among TNF inhibitors but requires more frequent administration 6
• Etanercept is the least effective of the TNF inhibitors 6
• TNF inhibitors should be avoided in patients with severe congestive heart failure (NYHA class III or IV), demyelinating disease, or recurrent serious infections 4

Pre-Treatment Screening Requirements

Before initiating any biologic for inverse psoriasis:

• Screen for active tuberculosis with history, physical examination, and tuberculin skin test or interferon-gamma release assay 2
• Assess for active infections or sepsis; defer treatment until resolved 2
• Screen for untreated hepatitis B infection (relative contraindication) 2
• Evaluate for history of inflammatory bowel disease, as IL-17 inhibitors may increase IBD risk 2
• Complete indicated killed vaccines before starting therapy; live attenuated vaccines must be given 2-4 weeks prior 2

Special Considerations for Inverse Psoriasis

Avoid injecting biologics into areas showing active psoriasis lesions 2. This is particularly relevant for inverse psoriasis given the typical involvement of axillae, groin, and inframammary areas.

Common Pitfalls to Avoid

• Do not use IL-12/23 inhibitors (ustekinumab) for patients with predominant axial/spondylitic disease, as trials in axial spondyloarthritis were stopped for lack of efficacy 5
• Monitor for mucocutaneous candida infections with IL-17 inhibitors, which occur at 1.9 per 100 patient-years but are typically mild 2
• For patients with concomitant active inflammatory bowel disease, use monoclonal antibody TNF inhibitors or ustekinumab instead of IL-17 inhibitors 5, 4

Dosing Adjustments

Overweight or obese patients often require higher doses of ustekinumab (90 mg vs 45 mg) to achieve equivalent response 4. The 300 mg dose of secukinumab is more effective than 150 mg and should be prioritized 2.

Combination Therapy

Combination with high-potency topical corticosteroids or vitamin D analogues can augment biologic efficacy, though published safety data on combinations is limited 2. This approach may be particularly useful for inverse psoriasis given the anatomical challenges of these areas 1.