What are the treatment options for a patient with moderate to severe plaque psoriasis who has failed other treatments?

Treatment of Moderate to Severe Plaque Psoriasis with Biologics

For patients with moderate to severe plaque psoriasis who have failed other treatments, initiate biologic therapy with adalimumab as first-line systemic treatment, dosed at 80 mg subcutaneous on Day 1, followed by 40 mg at Week 1, then 40 mg every 2 weeks thereafter. 1

Patient Selection Criteria for Biologic Therapy

Biologics are indicated when patients meet all of the following criteria: 1

• PASI ≥10 AND DLQI >10
• Failed, have contraindications to, or are intolerant of at least one conventional systemic therapy (methotrexate, cyclosporine, or PUVA)

Exception: For psoriatic arthritis of any severity, biologics are indicated regardless of skin disease extent. 1, 2

First-Line Biologic Selection Algorithm

Primary Recommendation: Adalimumab

• Dosing: 80 mg subcutaneous on Day 1, then 40 mg at Week 1, then 40 mg every 2 weeks 1, 3
• Efficacy: Achieves PASI 75 in 71% of patients at week 16 (vs. 7% placebo) 1, 2
• Assessment timepoint: Evaluate treatment response at 16 weeks 1
• Advantages: Treats both skin and joint symptoms, inhibits radiographic joint damage in psoriatic arthritis 1, 2

Alternative Option: Infliximab

• Dosing: 5 mg/kg IV at weeks 0,2,6, then every 8 weeks 4, 1
• Efficacy: Achieves PASI 75 in 80% of patients 1
• Assessment timepoint: Evaluate at 10-14 weeks 1
• Critical caveat: Must add methotrexate to reduce immunogenicity and prevent antibody formation 1, 2
• Never extend intervals beyond 8 weeks to avoid infusion reactions and loss of disease control 4

Third Option: Etanercept

• Dosing: 50 mg subcutaneous twice weekly for 12 weeks, then 50 mg once weekly maintenance 1, 2
• Efficacy: Achieves PASI 75 in 48-66% at week 12 1
• Assessment timepoint: Evaluate at 12 weeks 1

Site-Specific Recommendations

For palmoplantar psoriasis, nail psoriasis, and scalp psoriasis, adalimumab is strongly recommended regardless of overall skin disease severity (Strength A recommendation). 1

Etanercept is also effective for nail psoriasis and scalp psoriasis. 1

Combination Therapy to Augment Efficacy

When monotherapy provides inadequate response, add: 1, 2

• High-potency corticosteroids ± vitamin D analogues to etanercept for 12 weeks (Strength A) or to adalimumab for 16 weeks (Strength B)
• Methotrexate with any TNF inhibitor to reduce immunogenicity and prevent antibody formation (Strength B)
• Acitretin may be combined with biologics
• Narrowband UVB can enhance efficacy

Treatment Response Criteria

Success is defined as: 1

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

Critical Pitfalls to Avoid

Never use systemic corticosteroids (prednisone) for psoriasis due to poor long-term efficacy and severe rebound flares upon discontinuation. 1

Do not delay biologics in patients with >5% BSA involvement who meet criteria, as topical therapy alone will be insufficient. 4

Always add methotrexate to infliximab to prevent antibody formation and maintain efficacy. 1, 2

Avoid interrupted therapy with infliximab due to increased risk of infusion reactions and poorer disease control. 4

Safety Monitoring

Before initiating biologic therapy: 5, 3

• Screen for tuberculosis and other infections
• Ensure vaccinations are up-to-date
• Counsel patients about increased infection risk, including possible TB development even with negative baseline testing

Monitor closely for signs and symptoms of infection during and after treatment. 3

Be aware that lymphoma and other malignancies, including rare hepatosplenic T-cell lymphoma, have been reported with TNF blockers, particularly in adolescent and young adult males receiving concomitant azathioprine or 6-mercaptopurine. 3