Managing psoriasis is a bit of a minefield, and the plethora of treatment options can be overwhelming. So if you recently heard about biologics for psoriasis, you’re probably wondering what they are, how they work, and if they’re right for you. After all, most people with psoriasis will try anything under the sun to get these itchy, scaly plaques to pack up and leave the general vicinity of their body.
For those fortunate enough to be unfamiliar with this chronic inflammatory condition, psoriasis is an autoimmune disease that leads to thick, raised patches and scaly plaques on the skin, thanks to an overactive immune system that speeds up your skin’s cell turnover, according to the Centers for Disease Control and Prevention (CDC)1. The color of these plaques can range depending on your skin tone—on lighter skin it may appear pink, red, or silvery; whereas on darker skin it can appear dark brown, purple, or as light spots of hyperpigmentation. This unpredictable presentation is just one of the reasons why psoriasis is often harder to diagnose in people of color.
There is no shortage of advice out there for dealing with psoriasis—from internet hacks to unsolicited tips from strangers (if one more person tells us to cut out dairy, we just might scream). But when it comes to finding an evidence-based treatment method that really works for you, that can take a bit more work. Here, we’ve pulled together information about various psoriasis treatments, with a specific focus on biologics and biosimilars.
Treatments for psoriasis
Topical creams are often the first line of psoriasis treatment, particularly if you’re dealing with mild psoriasis. If that doesn’t work for you, then your provider might suggest something like light therapy, oral systemic therapy, or a biologic treatment. “I’ll give it a few months of topical treatments, and if that’s not [helping], then I’ll go with a biologic,” Kyle Cheng, M.D., health sciences assistant clinical professor at the David Geffen School of Medicine and director of the UCLA Psoriasis Specialty Clinic at UCLA Medical Center, tells SELF.
But if your psoriasis is on a part of your body that’s particularly difficult to treat, like your scalp, hands, feet, nails, armpit, or groin area, your doctor might go straight to suggesting a biologic, Dr. Cheng says. Also, if your psoriasis covers a larger amount of your skin or you’re developing any symptoms of psoriatic arthritis, a topical treatment likely isn’t going to do much for you, he says. So your doctor might suggest a biologic.
“Someone with one or two plaques on the legs could probably be treated with topical therapy very well,” Shari Lipner, M.D., Ph.D., dermatologist at Weill Cornell Medicine and NewYork-Presbyterian, tells SELF. “But the biologic therapy is used for more widespread disease or hard-to-treat areas, as well as [in] patients who may have psoriatic arthritis [where] you want to be more aggressive.”
Your doctor should also take your quality of life into account, Dr. Lipner says. Even if you have psoriasis on only a small part of your body, it can still cause you to be self-conscious if it’s on a particularly visible area of skin, for instance. So, in that case, your doctor may want to treat it more aggressively.
Let’s talk about the most common types of medications used to treat psoriasis. Buckle up, because there are a lot.
- Topical corticosteroids: As the typical first line of defense, these are prescribed most often for psoriasis, according to the Mayo Clinic2. These can come in creams, gels, ointments, sprays, or other solutions.
- Topical non-steroids: There are lots of things your provider may suggest putting on your skin for psoriasis relief, from topical retinoids and synthetic vitamin D analogues to calcineurin inhibitors and coal tar.
- Light therapy: Phototherapy for psoriasis involves exposing the skin to controlled amounts of light. While you might get some benefits from regular old sunshine, the National Psoriasis Foundation3 explains that phototherapy typically involves targeted sessions with a specific, narrow wavelength of UVB light source—either in the office or at home. Another option, called Psoralen UVA or PUVA, involves a UVA light source combined with a light-sensitizing agent. Before you ask, tanning beds are not recommended, as they give off mostly UVA light and can increase your risk of skin cancer.
- Oral systemic treatments: There are a few oral prescription drugs for psoriasis, including methotrexate, cyclosporine, and apremilast.
- Biologic treatments: Biologics are administered by either injection or IV to alter the body’s immune response. We’ll get into these more in a bit.
What is systemic treatment for psoriasis?
You may have heard your provider talk about systemic psoriasis treatment, as opposed to treating with topicals or light therapy. Systemic therapy means that the treatment gets where it needs to go through systemic circulation throughout the body, as opposed to putting a cream or a light directly on the affected area. In the case of psoriasis treatment, systemic therapies include oral treatments, injectables, and IV infusions, according to the National Psoriasis Foundation4.
What are biologics?
Biologic treatments are a type of drug given by IV or injection every few weeks or months, says Dr. Cheng. As we mentioned, psoriasis is an autoimmune disease—meaning that it results from a situation in which the immune system attacks a part of the body as if it were a pathogen—so biologics work by dampening the immune system response.
There are, generally, three major kinds of biologics on the market to treat psoriasis, says Dr. Lipner. They’re categorized by the specific component of the immune system they act on: tumor necrosis factor alpha inhibitors (TNF-alpha inhibitors), interleukin-17 inhibitors (IL-17 inhibitors), and interleukin-23 inhibitors (IL-23 inhibitors).
How do biologics work?
Psoriasis drugs like these work because they target a specific part of the immune system that’s involved in psoriasis, Dr. Cheng explains. But they accomplish that in slightly different ways.
The TNF-alpha inhibitors are generally older drugs (like adalimumab and infliximab), and because TNF-alpha is involved in a lot of normal bodily processes outside of psoriasis, targeting it could come with more side effects than newer options. Specifically, TNF-alpha is a type of protein called a cytokine, and it has actions all over the body related to infections and inflammation. That’s why, in addition to helping treat the symptoms of psoriasis, drugs that modulate TNF-alpha can also be helpful in treating conditions like inflammatory bowel disease and rheumatoid arthritis.
The newer options—those that target IL-17 (such as brodalumab and ixekizumab) or IL-23 (like risankizumab-rzaa and guselkumab)—are working on parts of the immune system that seem to play a large role in the formation of psoriasis plaques. So targeting them is less likely to affect the rest of your body than a TNF-alpha biologic might. Interleukins, another type of cytokine, are produced by white blood cells, which play a crucial role in the body’s immune responses. But different interleukins have different jobs and pathways in the body. Although IL-17 and IL-23 do seem to have minor roles in fighting infections, Dr. Cheng says, their most major role seems to be in psoriasis. Still, no biologic treatment is going to be 100% specific, Dr. Lipner says.
Depending on your symptoms, your doctor may recommend combining your biologic with another treatment, like topical medications or UV therapy. But biologics aren’t usually combined with each other, Dr. Cheng says.
Depending on which treatment you’re using, patients may see improvements with biologics within a month, Dr. Cheng says, and they’ll see maximum results within three months. That said, if you stop using the biologic, you can expect your psoriasis to come back. So patients who find success with biologics can probably expect to be on them for a while, Dr. Lipner says.
Biologics vs. biosimilars
Now that you’ve got biologics down, it’s time to talk about biosimilars. You can think of biosimilar drugs as a bit like generic drugs for biologics, but with few crucial differences. Unlike generics, biosimilar drugs aren’t exact copies of their corresponding biologic drug, according to the American Cancer Society5. That’s because biologics are made from biological sources, so we can’t replicate them the way we do with drugs made from chemical compounds. That said, biosimilars come from the same biological materials and are developed in a similar way to their corresponding biologics.
The U.S. Food and Drug Administration6 (FDA) explains that biosimilar medications go through rigorous testing to make sure that they are just as safe and effective as their corresponding biologics at treating a particular condition. So, why do we need biosimilar drugs? Well, if you’ve spent any time talking to your provider about biologics, you probably know they’re expensive. According to the American Cancer Society7, biosimilars may eventually give people more and cheaper treatment options, thanks to something called the Biologics Price Competition and Innovation Act (BPCIA), which lets the FDA shorten the approval process for biosimilars.
According to the National Psoriasis Foundation8, there are several biosimilars currently approved to treat psoriasis. The risks and side effects of biosimilars are thought to be the same as the risks and side effects of their associated biologic drug.
How to use biologics
Older biologics can be given via IV, but more recently developed biologics are given as subcutaneous injections (meaning they go under the skin). You may need an injection as often as every week or two, or as little as every few months, depending on the type of biologic and its approved dosing regimen.
If you need to get them more often, you may be given the option to do them yourself at home, Dr. Cheng says. Generally, the best place to inject it will be an area of your body with more body fat than most other parts, most commonly the thigh, Dr. Lipner says. But you’ll need to be careful to switch up where you inject the medications so you don’t get too sore in one spot, she cautions.
Different biologics produce noticeable changes at different rates, Dr. Cheng says. And, of course, every patient is different. But many people with psoriasis plaques start to see improvement within a month and see their maximum results in another two months.
“[Biologics] tend to be the quickest out of all the treatments we have for psoriasis, but they do vary,” Dr. Lipner says. For instance, patients with nail psoriasis should give a biologic drug a solid six months to decide whether it’s working, because cell turnover in your nails goes more slowly than other parts of the body.
Side effects of biologics
The most common side effects of getting a biologic are irritation and soreness around the injection site. But, like any medication that alters the way your immune system works, you will be more vulnerable to pathogens while taking a biologic. In practice, for most patients, that amounts to “about one more cold per year,” Dr. Cheng says.
But it’s a risk that’s worth talking over carefully with your doctor. They’ll likely want to make sure you’re up-to-date on all of your vaccinations before starting the biologic, Dr. Lipner says. Not only does being on a biologic increase your risk for new infections, but in some cases it also increases the risk that latent illnesses in your body might reappear, especially tuberculosis. So, if you show any reactivity to tuberculosis in particular, you’ll need to be treated for that before starting the medication, Dr. Lipner explains.
Once you’re on the biologic, you’ll have to be careful to avoid live vaccines, like the MMR vaccine, Dr. Cheng says. Attenuated (inactive vaccines), like the flu shot, are safe and recommended, though. The one exception is the nasal flu vaccine, which is a live vaccine, Dr. Cheng explains.
It’s worth noting that none of the COVID-19 vaccines are live vaccines, according to the CDC9, so they are safe to take even if you’re on biologics. Unfortunately, we don’t yet know what effect these immunosuppressant drugs have on the vaccine’s efficacy. Until we have more data, experts suggest continuing to be cautious even if you’re fully vaccinated.
Finally, there are some people who should only be on certain kinds of biologics, including people who are pregnant or trying to get pregnant. Not all biologics are approved for pregnancy, but some are, so that’s an important conversation to have with your doctor. Also, people with Crohn’s disease shouldn’t take certain biologics for psoriasis, but there are other biologics that could help with both conditions.
While there are possible side effects of psoriasis medication, having a detailed discussion with your provider about your symptoms, your health history, and your quality of life can help you find the right fit for you.
Because so many new treatments for psoriasis (including biologics) are coming out so quickly, “it’s a very exciting time in dermatology right now,” Dr. Lipner says. Treatments like these “can really change the patient’s quality of life,” she continues, so it’s crucial to see a dermatologist and find a treatment regimen that works for you.
- Centers for Disease Control and Prevention, Psoriasis
- Mayo Clinic, Psoriasis: Diagnosis and Treatment
- National Psoriasis Foundation, Phototherapy
- National Psoriasis Foundation, Systemics
- American Cancer Society, What Are Biosimilars?
- U.S. Food and Drug Administration, What Is a Biosimilar?
- American Cancer Society, What Are Biosimilars?
- National Psoriasis Foundation, Biologics
- Centers for Disease Control and Prevention, Myths and Facts about COVID-19 Vaccines