Considering Biologics and Shared Decision-Making in Moderate to Severe Plaque Psoriasis: Part 3

Conversation continued from part 2.

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.

Refractory Scalp Psoriasis

The third case at each event described a woman with long-standing psoriasis involving difficult-to-treat areas—particularly the scalp—and only partial response after 18 months on secukinumab. Intense itch, visibility concerns, and psychosocial impact were central considerations.

Case Insights From Mastro’s Roundtable

Mastro’s 47-year-old patient had 10 years of psoriasis, 5% BSA, and persistent scalp involvement. Partial response on elbows but minimal improvement on the scalp prompted a switch to bimekizumab.
Mastro presented pooled phase 3 BE RIGHT (NCT03598790) and BE RADIANT open-label extension data showing PASI 100 rates of the following¹:

• 75.7% at week 48
• 73.6% at week 96
• 70.2% at week 144

These data reinforced durability and the value of dual IL-17A/F inhibition. One attendee added a real-world perspective: “I have a patient [whose disease] has failed 2 different IL-17s. I just started her on an IL-17A/F inhibitor, and she said after her visit check-in that her hands don’t hurt anymore, related to her [PsA].” Mastro also emphasized the diagnostic implications: “This case provided a great example of another high-impact/low-BSA example, which can be difficult on the documentation end. The larger take-home point was the concept of PsA and how we approached, graded, asked questions, and referred to rheumatology. Here we also dug a lot into the safety of the IL-17 class, which is critical from our patient narrative side, but also how we look at them relative to the other classes of biologics,” Mastro said.

Case Insights From Pansch’s Roundtable

Pansch’s group discussed several treatment adjustments for their 49-year-old patient, including the possibility of increasing the dose, adding adjunctive therapies such as topical agents, or switching biologics. The decision involves evaluating outcomes, such as PASI scores, safety profiles, and patient-reported improvements.

The discussion explored scalp-specific challenges, including the following:

• Thick stratum corneum
• Need for potency
• Slow response rates
• Psychosocial burden

Clinicians also discussed when to refer for mental health support if a patient’s distress is significant.

Case Insights From Rubin’s Roundtable

Rubin’s group echoed similar switching strategies for their 49-year-old patient. The group discussed mechanistic differentiation–guided decision-making, from IL-17A to IL-17A/F, or from IL-17 to IL-23.
An attendee summarized the practical sequencing mindset: “Some people like having a backup. I may start with an IL-17A. If it works, that’s great. If not, I have bimekizumab as a backup.”
Rubin also encouraged incorporating regular PASI, Investigator Global Assessment, and subjective progress assessments to guide timely changes.

Case Summary

Key shared observations included the following:

• Scalp psoriasis requires potent, targeted, often fast-acting therapies.
• Partial response after 18 months justifies switching.
• IL-17A/F inhibition offers enhanced benefit for refractory areas.
• Detailed PsA screenings should be part of every chronic psoriasis visit.

Themes and Clinical Takeaways

Several unifying themes emerged clearly across all 3 Case-Based Roundtable events:

Mechanistic Understanding Shapes Treatment Sequencing

IL-17 vs IL-23 mechanisms were central to nearly every discussion. Clinicians repeatedly evaluated the following:

• Onset speed
• Durability
• Nail vs skin efficacy
• Psoriatic arthritis implications
• Safety and tolerability

IL-17 inhibitors were frequently chosen for rapid clearance, especially for patients with visible plaques or high psychosocial burden. IL-23 inhibitors were often selected for durability, nail disease, and favorable safety perception.

Expectation Management Is Critical

All presenters emphasized patient communication, including the following:

• Realistic timelines
• Differences between steroid speed and biologic speed
• Dosing expectations
• Adherence requirements
• Safety discussions (especially candidiasis risk with IL-17 inhibitors)

As Rubin stated, “Your word is what they remember.”

Lifestyle Considerations Guide Practical Therapeutic Choices

Occupational factors such as outdoor work, limited follow-up availability, and travel schedules strongly influenced dosing selection and regimen preference. Convenience consistently correlated with adherence.

Nail Disease and Scalp Disease Require Targeted Strategies

Both conditions significantly shape therapeutic decisions:

• Nail involvement often indicates deeper inflammation and possible PsA risk.
• Scalp disease remains notoriously difficult, requiring potency and rapid onset.
• These conditions often justify switching biologics sooner.

Shared Decision-Making Improves Adherence

Clinicians across all roundtables shared similar conversational frameworks:

• Presenting multiple options
• Aligning choices with patient goals
• Acknowledging patient autonomy
• Offering transparent clinical recommendations

Data-Driven Discussions Enhances Confidence

Each presenter incorporated study data to support clinical decisions. As Mastro said, “When we get into groups, it’s always really powerful because we can look at and talk about objective data.”

Peer Discussion Enhances Clinical Practice

All 3 leaders highlighted the value of collaborative learning:

“I think the patient cases presented allowed an open dialogue amongst all the attendees in an environment that fostered honesty. I felt the attendees learned from each other, and I’ve received some notes from attendees already indicating they’ve tried something new that was discussed at the Case-Based Roundtable,” Pansch said.

“It’s having the time to truly discuss how we talk about these concepts with patients.… What you learn…is far stickier than a didactic lecture,” Mastro said.

Rubin also reinforced the importance of shared practical strategies in guiding complex decisions.

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. Gisondi P, Merola J, Thaci D, et al. Bimekizumab efficacy in patients with psoriasis and risk factors for psoriatic arthritis: 3‑year results from 5 phase 3/3b studies. Poster presented at: International Congress of Dermatology; June 18-21, 2025; Rome, Italy.