Considering Biologics and Shared Decision-Making in Moderate to Severe Plaque Psoriasis: Part 1

Across a series of recent Dermatology Times Case-Based Roundtable events, Andrew Mastro, MS, PA-C; Leigh Ann Pansch, MSN, FNP-BC, DCNP; and Cory Rubin, MD, led discussions focusing on managing moderate to severe psoriasis with systemic therapies. The events, led by Mastro in Chicago, Illinois; Pansch in Cincinnati, Ohio; and Rubin in Detroit, Michigan, brought together community clinicians to discuss similar patient scenarios, examining therapeutic decision-making, biologic options, and the growing emphasis on patient-centered care.

Mastro is a physician assistant at the Illinois Dermatology Institute; Pansch is a physician assistant at DOCS Dermatology; and Rubin is a dermatologist and founder of the Michigan Dermatology Institute.

Collectively, the conversations highlighted available biologics such as IL-17 and IL-23 inhibitors; considerations for body surface area (BSA) impact; and the importance of empathy, access, and shared decision-making for optimizing outcomes.

Moderate Plaque Psoriasis With Lifestyle Considerations

The first case presented at each event centered on a man aged between 36 and 40 years with moderate psoriasis involving the scalp, arms, and lower extremities (approximately 10% BSA), with moderate itch and significant quality of life burden. All 3 moderators framed this case type as a common clinical scenario in which topical therapies are inadequate, follow-up availability may be limited, and patients often express a strong preference for quick, noticeable improvement.

Case Insights From Mastro’s Roundtable

In Mastro’s session, the patient, a 36-year-old man, presented with a 6-month history of plaque psoriasis affecting about 10% BSA, with minimal improvement from prior use of triamcinolone 0.1% cream and clobetasol shampoo. The patient’s work as a landscaper created barriers to follow-up and generated additional concerns, such as sun exposure, sweat, and outdoor irritation.

Given the need for rapid, durable control and convenient maintenance, bimekizumab (Bimzelx; UCB), an IL-17 inhibitor, was recommended.

As one attendee commented: “Among biologics, IL-17s are definitely the fastest.”

Another added: “I think the reason why some of the IL-17s on the market aren’t as durable as the IL-23s is because there are so many more IL-17 sectors than there are in IL-23.”

Mastro’s data presentation referenced the phase 3 BE RADIANT study (NCT03536884),¹ noting week 16 Psoriasis Area and Severity Index (PASI)100 rates of the following:

• 61.7% for bimekizumab
• 48.9% for secukinumab (Cosentyx; Novartis)

He emphasized the need to balance patients’ desire for speed with realistic expectations. Many attendees agreed that biologics work quickly compared with traditional options, but “not necessarily the speed of high-potency topical steroids.”

Mastro summarized the learning value: “This case presented a great example of when speed and efficacy must meet in order to satisfy the patients’ needs. This taught the group how to approach a patient who is caught in a treatment cycle with little benefit, and how to approach the psychosocial end. We also discussed the mechanistic differences with the IL-17 class, and teasing out the IL17A/F vs just A.”

Case Insights From Pansch’s Roundtable

Pansch’s discussion featured a nearly identical case—a 40-year-old park ranger with similar disease distribution and similar quality of life disruption. The group again selected bimekizumab, emphasizing the following:

• Objective severity measures
• Patient lifestyle constraints
• Realistic expectations
• Monitoring for oral candidiasis

The roundtable also discussed escalation criteria, follow-up frequency, and alternative options if the patient experienced treatment failure.

“There was great discussion about the potential risk of psoriatic arthritis [PsA] and how various clinicians evaluate, diagnose, and treat patients with PsA. We heard evidence of a solid knowledge base regarding the identification of PsA and how to treat these patients. There was knowledge of systemic therapies approved to treat PsA as well as discussion of speed of onset,” Pansch said.

Case Insights From Rubin’s Roundtable

Rubin’s case mirrored the others closely. The group agreed on bimekizumab, highlighting both onset and convenience. Rubin added a practical point regarding its dosing flexibility: “Bimekizumab is one of the only, if not the only, biologic without a true loading dose.”

Another attendee expanded on patient-centered conversation:

“I tell my patients, ‘If it were me or somebody in my family, this is the drug I would use, here’s why, and here are the other options.’”

Case Summary

Across all 3 groups, this case highlighted the following:

• Rapid-acting IL-17 inhibitors remain highly valued when speed matters.
• Lifestyle-driven dosing schedules play a major role in adherence.
• Expectation management is central to successful outcomes.
• Topicals may not be appropriate for moderate disease or challenging sites.

Conclusion

Through 3 cases presented across Dermatology Times Case-Based Roundtable events, expert clinicians collectively examined the evolving landscape of systemic psoriasis therapy. Together, the discussions showcased the nuances of individualizing biologic selection, adjusting therapy based on objective and subjective indicators, and applying mechanistic understanding to optimize long-term outcomes.

Reference

1. Reich K, Warren RB, Lebwohl M, et al. Bimekizumab versus secukinumab in plaque psoriasis. N Engl J Med. 2021;385(2):142-152. doi:10.1056/NEJMoa2102383