It’s Time to Treat Moderate Psoriasis Seriously

Image Credit: © DermNet

Our understanding of moderate plaque psoriasis is evolving. Once narrowly defined by body surface area (BSA) and composite severity scores, moderate psoriasis is increasingly recognized as a disease category that can significantly impair quality of life, even when lesion extent is limited. This shift has been accompanied by new classification frameworks, more inclusive systemic treatment eligibility criteria, and growing consensus around meaningful long-term treatment targets such as on-treatment remission.

Rethinking Systemic Eligibility

Traditionally, systemic therapy was reserved for patients with Psoriasis Area and Severity Index (PASI) scores above 10 or at least 10% BSA involvement. However, these thresholds do not fully reflect disease burden in patients with involvement of sensitive or functionally critical areas, such as the scalp, face, genitals, palms, soles, and nails. The International Psoriasis Council (IPC) has proposed a reclassification that considers systemic therapy appropriate for patients with high-impact site involvement, BSA greater than 10%, or inadequate response to topical therapies.¹ 

This redefinition is supported by real-world evidence. Data from the CorEvitas Psoriasis Registry show that a substantial proportion of patients initiating systemic therapy have 10% or less BSA involvement, often because their disease affects visible or high-impact sites.² Similarly, the UPLIFT survey—a multinational cross-sectional study— found that patients with limited BSA but psoriasis in sensitive areas report disproportionately high levels of pruritus, pain, functional limitation, and emotional distress.³ These findings challenge traditional severity cutoffs and emphasize the need to assess treatment eligibility based on impact, not just extent.

Aligning Treatment Choice With Patient Needs

Once systemic therapy is deemed appropriate, selecting the right treatment involves careful consideration of clinical characteristics, comorbidities, patient preferences, and treatment goals. Increasingly, there is recognition that many systemic eligible patients with moderate psoriasis may benefit from therapies that offer greater depth and durability of response. 

The IMMpulse study (NCT04908475) provides supporting evidence for this approach.⁴ This phase 4, assessor-blinded trial enrolled adults with moderate plaque psoriasis eligible for systemic treatment and compared a PDE4 inhibitor, apremilast (Otezla; Amgen), with an IL-23 inhibitor, risankizumab (Skyrizi; AbbVie). By week 16, patients receiving risankizumab (an injection administered once every 3 months) achieved significantly higher rates of PASI 90 (55.9%) and Static Physician’s Global Assessment (sPGA) 0 or 1 (75.4%) compared with those on twice-daily oral apremilast (5.1% and 18.4%, respectively). Among apremilast non-responders who switched to risankizumab at week 16, 72.3% achieved PASI 90 and 50.6% achieved PASI 100 by week 52. Risankizumab consistently delivered higher complete clearance rates, with no new safety signals observed.⁴

These findings underscore that moderate disease severity does not preclude the need—or the benefit—of highly effective treatment. For patients with high-impact site involvement or inadequate response to initial therapy, timely consideration of therapies that can induce higher clearance levels may improve both disease control and quality of life.

On-Treatment Remission as a Shared Benchmark 

The 2025 National Psoriasis Foundation consensus defined on-treatment remission as maintaining BSA of 0% or an Investigator Global Assessment (IGA) score of 0 for at least 6 months while on therapy.⁵ This definition emerged from a multi-stakeholder Delphi process involving clinicians, researchers, patients, and payers. It marks a shift toward a clearer, patient-centered benchmark for treatment success. This concept of on-treatment remission complements existing PASI-based metrics by emphasizing sustained clearance and stability. Although not every patient will achieve this outcome, setting remission as an aspirational but attainable target can help guide treatment optimization and shared decision-making. Importantly, this benchmark reflects the long-term disease control that patients value and that health systems increasingly prioritize. In the IMMpulse study, for example, a meaningful proportion of patients receiving an IL-23 inhibitor achieved complete clearance (PASI 100 and sPGA 0), and many sustained these outcomes beyond 16 weeks, particularly among those who switched from less effective therapy. These data illustrate that on-treatment remission is achievable in routine clinical scenarios when appropriate therapies are selected.

New Oral Agents on the Horizon 

The psoriasis treatment landscape continues to expand with promising oral therapies. Zasocitinib (Takeda), a selective TYK2 inhibitor, demonstrated PASI 75 in 67%, PASI 90 in 46%, and PASI 100 in 33% of patients at week 12 in a phase 2b trial.⁶ Icotrokinra (Protagonist Therapeutics and Janssen Biotech), a first-in-class oral IL-23 receptor antagonist, achieved 65% IGA 0/1 and 50% PASI 90 at week 16 in the phase 3 ICONIC-LEAD trial (NCT06095115) compared with 8% and 4%, respectively, in the placebo group.⁷ Although these emerging agents may broaden options for patients who prefer oral therapy, many patients continue to value the extended dosing intervals offered by some biologics, which support long-term adherence and convenience.

Considering Disease Trajectory

Emerging data also suggest that early treatment decisions may in uence longer-term disease trajectory. A recent population-based analysis of more than 7000 patients with psoriasis found that those initiating IL-23 inhibitors had a significantly lower incidence of new-onset inflammatory arthritis than those starting TNF or IL-17 inhibitors.⁸ Although additional studies are needed to confirm causality, this observation raises important questions about the potential disease-modifying properties of early IL-23 inhibition, particularly in patients at elevated risk for psoriatic arthritis (PsA). This reinforces the broader need to take a proactive, longitudinal view of psoriasis management. Treatment goals should extend beyond skin clearance to include comorbidity prevention (especially PsA), functional preservation, and patient-reported outcomes.

The Path Forward

Moderate plaque psoriasis is not a trivial condition. Even with limited BSA involvement, disease affecting high-impact sites can profoundly affect quality of life. Also, PsA can exist in patients with plaque psoriasis with limited BSA involvement. With updated eligibility criteria, strong evidence such as the IMMpulse study, evolving benchmarks for ontreatment remission, and an expanding pipeline of effective oral therapies, dermatologists now have the tools to deliver patient-centered, goal-directed care. The era of undertreating moderate psoriasis must end. With new data, better definitions, and clearer treatment targets, we have the tools to raise expectations and outcomes. It is time to match our clinical strategy with the realities our patients live every day.

References

1. Strober BE, Blauvelt A, van de Kerkhof PC, et al. International Psoriasis Council psoriasis disease severity reclassification: update on validity, acceptance, and implementation. J Am Acad Dermatol. Published online June 6, 2025. doi:10.1016/j.jaad.2025.05.1445
2. Armstrong AW, Feldman SR, Fitzgerald T, et al. Patient reported outcomes by baseline body surface area involvement among individuals initiating biologic therapy: results from the CorEvitas Psoriasis Registry. Dermatol Ther (Heidelb). 2025;15(8):2117-2130. doi:10.1007/s13555- 025-01456-5
3. Merola JF, Ogdie A, Gottlieb AB, et al. Patient and physician perceptions of psoriatic disease in the United States: results from the UPLIFT survey. Dermatol Ther (Heidelb). 2023;13(6):1329-1346. doi:10.1007/s13555-023- 00929-9
4. Stein Gold LF, Bagel J, Tyring SK, et al. Comparison of risankizumab and apremilast for the treatment of adults with moderate plaque psoriasis eligible for systemic therapy: results from a randomized, open-label, assessor blinded phase IV study (IMMpulse). Br J Dermatol. 2023;189(5):540-552. doi:10.1093/bjd/ljad252
5. Armstrong AW, Gondo GC, Merola JF, et al. Defining on-treatment remission in plaque psoriasis: a consensus statement from the National Psoriasis Foundation. JAMA Dermatol. Published online June 18, 2025. doi:10.1001/ jamadermatol.2025.1625
6. Armstrong AW, Gooderham M, Lynde C, et al. Tyrosine kinase 2 inhibition with zasocitinib (TAK-279) in psoriasis: a randomized clinical trial. JAMA Dermatol. 2024;160(10):1066-1074. doi:10.1001/jamadermatol.2024.2701
7. Icotrokinra results show potential to set a new standard of treatment in plaque psoriasis. News release. Johnson & Johnson. March 8, 2025. Accessed July 14, 2025. https://www.jnj.com/media-center/press-releases/ icotrokinra-results-show-potential-to-set-a-new-standard-of-treatment-in-plaque-psoriasis
8. Strober B, Soliman AM, Li C, Patel M, Unigwe I, Gisondi P. Risk of developing inflammatory arthritis in patients with psoriasis initiating treatment with biologics: a population-based analysis. J Am Acad Dermatol. 2024;91(6):1143-1149. doi:10.1016/j.jaad.2024.06.106