Starting biologics earlier leads to better skin clearance, improved quality of life and lower risk of other health issues compared to standard step-by-step care in moderate-to-severe psoriasis, according to a recent analysis of real-world registry data.
The study, published in the British Journal of Dermatology and based on the British Association of Dermatologists Biologics and Immunomodulators Register of patients with psoriasis in the UK and Ireland, compared the clinical effectiveness and the risk of incident comorbidities over five years between biologics used as first-line systemic therapy and standard care pathways involving conventional agents such as methotrexate or ciclosporin.
Participants included 3,702 adults with moderate-to-severe psoriasis (baseline Psoriasis Area and Severity Index [PASI] score ≥10) and no prior systemic therapy. Of these, 334 commenced biologics as first-line treatment and 3,368 received standard care.
Psoriasis control with early biologic use
The primary outcome of the change in PASI over five years favoured favoured early biologic use. At one year, the mean PASI was 2.4 (95% CI 2.0–2.9) in the biologic group versus 6.7 in the standard care group – a difference that persisted at five years (2.0 vs 4.7).
Secondary outcomes also favoured biologics over standard care. Dermatology Life Quality Index scores were lower at one year (4.0 vs 7.9) and five years (3.5 vs 5.6).
Complete skin clearance was achieved in 58.6% of early biologic initiators compared with 32.1% of those receiving standard care, with a significantly higher likelihood of clearance (hazard ratio [HR] 2.85; 95% CI 2.34–3.47). Time to clearance was also shorter with biologics (13.3 vs 23.3 months).
There was some variation between biologic classes, with interleukin (IL)-23 inhibitors achieving the highest cumulative PASI 0 rates (91.2%), compared with 67.0% for IL-17 inhibitors and around 48% for tumour necrosis factor and IL-12/23 inhibitors.
Comorbidity risk and treatment pathway implications
Beyond skin outcomes, early biologic use was associated with a lower risk of developing new chronic comorbidities over five years. Cumulative incidence was 47.5% in the biologic group versus 54.3% with standard care (HR 0.72; 95% CI 0.58–0.89).
Risks of mental health disorders (HR 0.64; 95% CI 0.44–0.94) and hepatic disease (HR 0.54; 95% CI 0.38–0.76) were also reduced, which might reflect improved disease control, reduced systemic inflammation and avoidance of hepatotoxic conventional therapies, although causality cannot be confirmed.
Baseline differences showed that biologic initiators were older and had greater comorbidity burden prior to adjustment, suggesting potential confounding by indication. However, weighting achieved good covariate balance, supporting the robustness of the findings.
Limitations included potential residual confounding from socioeconomic factors, incomplete adjustment for alcohol use and variability in outcome measurement over time, the authors said.
Despite these constraints, the findings suggested that stepwise treatment pathways that delay biologic therapy may need reconsideration.
Earlier initiation could reduce cumulative disease burden and improve long-term outcomes, but the authors noted that updated cost-effectiveness analyses that incorporate biosimilar pricing, alongside prospective studies to confirm long-term benefits and optimise patient selection, are warranted.
Reference
Phan DB et al. Using biologic therapies as first-line systemic treatment for psoriasis: a cohort study following the target trial emulation framework from BADBIR. Br J Dermatol 2026;Mar 16:ljiag098.
This article was originally published by our sister publication Hospital Healthcare Europe.
