Biologics are the most recent advances in the treatment of psoriasis, though they have been in use in the U.S. for nearly 14 years. Biologics were initially considered 2nd line agents, but can now be considered 1st line therapy for severe, diffuse or resistant cases of psoriasis.
These drugs include such tongue-twisting names as infliximab, etanercept, adalimumab, and ustekinumab.
Biologics are often easy to use and offer dosing regimens that range from twice a week to once every 3 months. They also appear to be very safe, with minimal lab monitoring, and low side-effect profile.
Biologics should be considered when someone has psoriasis that is limiting their daily life in terms of function or psychosocially. Some examples of this include the following:
- When psoriasis covers large areas of the body so that applying a topical medication to all of the affected areas is impractical. In such cases, using a “whole body” therapy, such as biologics, might be considered.
- When psoriasis is especially severe, even if the affected area is limited. Examples include severe/resistant hand psoriasis in a surgeon or pianist, facial psoriasis in an actress or newscaster, or foot psoriasis in an athlete.
- Psoriasis that requires “whole body” therapy, but has failed other, non-biologic treatments, such as UV phototherapy, methotrexate, and acitretin to name a few.
Each case of psoriasis has unique characteristics and each individual has a unique health history and lifestyle. These variables may make one medication a better fit for a particular patient than another.
In general, make sure you consult with a board-certified dermatologist who is experienced with treatment of complicated psoriasis.
In general, I tend to prescribe etanercept (Enbrel®) and adalimumab (Humira®) as my first agents — both have a long track record of safety with excellent effectiveness, and are quite similar in their mode of action.
Ustekinumab (Stelara®) is the newer kid on the block, and for this reason, I generally reserve it if someones fails or does not respond sufficiently to my first options. Because Stelara® works by a different mechanism of action, there are some patients in which it may be my first line agent. Infliximab (Remicade®), while probably the most potent, also has a higher side-effect profile and requires an IV infusion, so I reserve this for my most resistant patients.