Considering Biologics and Shared Decision-Making in Moderate to Severe Plaque Psoriasis: Part 2

Conversation continued from 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.

Psoriasis With Nail Involvement

The second case in each roundtable centered on a 41- to 42-year-old man with plaque psoriasis involving approximately 8% BSA, new or worsening nail involvement, and diminishing response to ustekinumab (Stelara; Janssen).

Nail psoriasis served as a critical focal point, often described as a high-impact finding reflecting deeper inflammatory activity and potential PsA risk.

Case Insights From Mastro’s Roundtable

Mastro’s second case involved a 41-year-old man with long-standing plaque psoriasis and new-onset pitting/onycholysis interfering with work and hobbies (piano playing, typing). After losing response to ustekinumab, the group opted for risankizumab (Skyrizi; AbbVie), an IL-23 inhibitor.

Mastro reviewed data from the phase 3 UltIMMa-1 and UltIMMa-2 trials (NCT02684370; NCT02684357)¹:

Week 16 PASI 100:

• 36% with risankizumab
• 12% with ustekinumab

Week 52 PASI 100:

• 56% with risankizumab
• 21% with ustekinumab

“This case presents a great example of a high-impact area like the nails, and how much of a burden this can be for our patients. This also presents an opportunity for us to advance their therapy to a biologic, recognizing that the changes in the nails likely require it. The concept of flare vs failure is a take-home point, which can be hard to differentiate. However, the discussion on differences with IL-23 and IL-17 was key, especially the idea that IL-23 is the class with durability, which I think was challenged with what we discussed for bimekizumab,” Mastro said.

Case Insights From Pansch’s Roundtable

Similarly, Pansch presented the case of a 42-year-old man with nail psoriasis and waning response to ustekinumab. The group selected risankizumab, noting the following:

• Family history of ulcerative colitis
• Dosing preference (12-week schedule)
• Nail improvement potential
• Need to monitor for PsA

The importance of patient participation in therapeutic escalation was highlighted, with shared decision making emphasized as a strategy to improve satisfaction and adherence.

“I thought the clinicians formulated excellent treatment plans related to what therapies would be appropriate for case No. 2. There was discussion of [the] patient’s requests/desires in a systemic therapy and which therapies approved meet the goals of the patients,” Pansch said.

Case Insights From Rubin’s Roundtable

Rubin’s attendee discussions echoed the same themes of a 42-year-old man. For patients with nail involvement, many clinicians consider IL-23 inhibitors reliable and well tolerated. As one attendee stated: “I like the safety of the IL-23s. You can tell your patients that they’re not going to have any adverse effects.”

Rubin also highlighted nail disease as a warning sign that deeper inflammation may be present—and possibly early PsA. With 8% BSA and a family history of ulcerative colitis, the patient’s case highlighted the importance of mechanism selection and safety considerations.

Rubin’s group also selected risankizumab, as the 12-week dosing schedule was suited to the patient’s preference.

Case Summary

Common themes across the groups included the following:

• Nail psoriasis significantly influences therapeutic choice.
• IL-23 inhibitors (particularly risankizumab) demonstrate strong cutaneous and nail efficacy.
• Recognizing the difference between a disease flare and biologic failure is essential.
• Nail disease may signal broader systemic inflammation and justify early escalation.

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. Gordon KB, Strober B, Lebwohl M, et al. Efficacy and safety of risankizumab in moderate-to-severe plaque psoriasis (UltIMMa-1 and UltIMMa-2): results from two double-blind, randomised, placebo-controlled and ustekinumab-controlled phase 3 trials. Lancet. 2018;392(10148):650-661. doi:10.1016/S0140-6736(18)31713-6