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Psoriasis: A Year-in-Review

Psoriasis: A Year-in-Review

Research and Clinical Studies
Each year comes with new advances in treatment options, and 2019 was no exception. Research further characterized methods of action and considerations for biologics, such as the effects of biologics on plaque in coronary arteries and the IL-17 inhibitor impact on inflammatory bowel disease. In psoriasis, biologics affect T-cell activity by acting on proteins, including tumor necrosis factor (TNF) alpha, IL-12, IL-23, and IL-17. Some biologics may even help treat comorbidities in patients with psoriasis; this is new knowledge due to recently published research surrounding biologics slowing or preventing the
progression of comorbidities.Psoriasis in white patient

According to the findings of a recent study,1 biologic therapies may reduce coronary plaques in patients with psoriasis. “Psoriasis severity is related to the burden of coronary disease–our findings suggest treating the psoriasis may potentially benefit coronary heart disease,” said corresponding author Nehal Mehta, MD, MSCE, FAHA, chief of inflammation and cardiometabolic diseases at the National Heart, Lung, and Blood Institute with the National Institutes of Health in Bethesda, MD, in a press release.2

In the prospective observational study, 121 participants with psoriasis who had not been treated with biologics at baseline were recruited. Mean participant age was 50.2 years, more than half of the participants were male (n=70) with low cardiovascular risk based on the Framingham risk score, and participants had moderate to severe skin disease at baseline. Total coronary plaque burden and plaque subcomponents (calcified and noncalcified) in the three main coronary vessels were assessed by a reviewer blinded to the treatment group.

Elnabawi et al1 found treatment with a biologic was associated with a 6% reduction in noncalcified plaque burden and reduction in necrotic core, with no effect on fibrous burden. In comparisons between plaque characteristic changes over 1 year, they observed that decreases in noncalcified plaque burden associated with biologic treatment were significant compared with slow plaque progression among those not treated with biologics and were associated with biologic therapy after adjusting for traditional cardiovascular risk factors.

In addition to cardiovascular benefits, researchers found that patients with psoriasis and concurrent malignancy may be safely treated with biologic therapies and apremilast (Otezla) without the risk of recurrence or progression of cancer.3

Although many studies have assessed the risk of developing malignancy during treatment, few have assessed the use of biologic therapy among patients with a history of established malignancy, the researchers said. They conducted a retrospective chart review of 690 patients with psoriasis who attended their clinic between January 1, 2012, and May 31, 2018. Sixteen patients with a history of malignancy, excluding nonmelanoma skin cancer, who were treated with biologics or apremilast were identified.

The researchers found that the average time from cancer diagnosis to initiation of biologics or apremilast was 4.7 years, with nine patients (56%) initiating treatment within 5 years. Three patients (19%) received concurrent cancer therapy during biologic treatment, the researchers observed.

Out of 16 patients, none experienced clinical or radiographic recurrence or progression of their cancer during biologic treatment, and most patients experienced improvements in their psoriasis.3

In an abstract presented at the annual meeting of the American College of Rheumatology and Association of Rheumatology Professionals, a research group from New York University School of Medicine found a larger percentage of patients with psoriatic arthritis (PsA) and depression received treatment with biologics than their nondepressed counterparts, but the patient outcomes varied between the two groups.4

Haberman et al4 prospectively recruited 436 patients (54% men, mean age 47 years, 74.1% Caucasian) who met Classification Criteria for Psoriatic Arthritis criteria. Of these patients, 19.5% had depression and 15.6% had anxiety. They found that patients with PsA and depression were more likely to receive treatment for PsA (80% vs 65%; P=.01) and had a higher percentage of biologic use (47.5% vs 40.4%; P=.126) than those without depression.

The authors compared disease severity between the two groups. Patients with PsA and depression had a statistically significant lower mean of psoriatic activity as measured by body surface area (BSA) than the nondepressed cohort (1.4% vs 3.03%; P=.001). The group with depression also had a statistically significant higher mean RAPID3 score than the nondepressed group (12.7 vs 10.4;  P=.035); the authors hypothesized that the contrast between patient-reported outcomes (RAPID3) and the BSA of psoriatic activity could be a “manifestation of how depression could affect the way patients experience their PsA despite apparent improvement in skin and joint symptoms.”4

Furthermore, their study concluded that depression should be considered a “critical comorbidity” of PsA.4 This is similar to another 2019 study5 that examined psychopathological and sexual consequences related to psoriasis. In a comparative study between 220 patients with psoriasis (110 men, 110 women) and 220 age- and sex-matched healthy controls, researchers found significantly higher rates of depression, anxiety, and low self-esteem in patients with psoriasis. The researchers5 noted that women had a significantly higher frequency of self-reported sexual dysfunction than men and that this dysfunction was commonly affected by depression, presentation of psoriasis on genital areas, and increased disease severity.

“Assessment of psychopathological and sexual comorbidities in psoriasis patients and [their] partners should be an integral part of the management plan,” concluded the authors.5

New Therapies Available
The number of treatment options available for patients increased in 2019 with the addition of several new therapeutics approved by the FDA. 

The FDA approved Skyrizi (risankizumab-rzaa), an IL-23 inhibitor, for the treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy.6 This treatment is administered as two 150-mg subcutaneous injections every 12 weeks following two initiation doses at week 0 and 4. Patients can administer the injections themselves after training or can elect to have the therapy administered in an office setting.7

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