Biologics have radically shifted the treatment for moderate-to-severe psoriasis. And for good reason: Research shows they can clear skin more effectively and more safely than conventional treatments. But that doesn't mean you don't have questions, and probably a bunch of them, too. We've got the answers below.
What Are Biologics?
Biologics are medicines made from substances found in living things (including humans, animals, and microorganisms). They are protein-based molecules that act like antibodies. Your natural antibodies are the cells that target bacteria and viruses. Similarly, biologics target and block the specific proteins that fuel your psoriasis symptoms. (If your condition has advanced to psoriatic arthritis, a biologic can also stop the pain, stiffness, and swelling in your joints.) However, because biologics are composed of large molecules that can’t cross the stomach lining, the medicine has to be injected into your skin or infused into your bloodstream via an IV.
How Are Biologics Different From Traditional Drugs?
Conventional psoriasis drugs are made through a chemical process, while biologic agents are created from bacterial strains, says Joshua Zeichner M.D., director of cosmetic and clinical research in dermatology at Mount Sinai Hospital in New York City. Unlike systemic drugs that affect the entire immune system, biologics target only certain proteins called T cells, such as tumor necrosis factor-alpha (TNF-alpha), interleukin 17-A, or interleukins 12 and 23. These cells all play a major role in developing psoriasis.
What Are Some Examples of Biologic Drugs?
There are many FDA-approved biologic drugs for psoriasis on the market right now. These include:
- Cimzia (certolizumab pegol)
- Cosentyx (secukinumab)
- Enbrel (etanercept)
- Humira (adalimumab)
- Ilumya (tildrakizumab-asmn)
- Remicade (infliximab)
- Siliq (brodalumab)
- Simponi (golimumab)
- Skyrizi (risankisumab-rzaa)
- Stelara (ustekinumab)
- Taltz (ixekizumab)
- Tremyfa (guselkumab)
This chart breaks down which biologics target which proteins.
How Bad Does My Psoriasis Have to Be to Begin Using a Biologic?
Biologics are recommended for those with moderate-to-severe psoriasis. Moderate psoriasis means that 3% to 10% of your body is covered in psoriasis and severe psoriasis means that more than 10% of your body is covered.
However, there are instances when even those with mild psoriasis may want to try biologics. “If your face, hands, or genitals are affected, it may have a significant impact on quality of life, even if the surface area is small, says Dr. Zeichner. If your psoriasis is not responding to medications ranging from topical treatments to light therapy, or if your body doesn’t react well to systemic treatments, then biologics is the next option.
What Are the Risks of Biologics?
Biologics can increase your risk of infections like the flu, sinus infections, and upper-respiratory tract infections, says dermatologist Howard Sobel M.D., founder of Sobel Skin in New York City. That's because the immune system basically functions as a team. “One cell signals another to activate a particular immune response,” Dr. Sobel explains. Biologics, however, block the action of some of those cells, which helps your skin but also makes it a little harder to ward off germs.
As with all medicine, there's also a risk of allergic reaction. Dr. Sobel notes that psoriasis sufferers who have allergic reactions to biologics may exhibit redness, itchiness, chills, shortness of breath, or injection-site swelling, and the possibility of a full-body rash. “Some patients may see adverse reactions, including a secondary immune-related issue like lupus or atopic dermatitis and other hypersensitivity reactions,” Dr. Sobel says. “Depending on the type of biologic, there may be a slight increased risk of diarrhea, oral herpes, headaches and rashes.”
Other risks to know about: Biologics can reactivate a latent tuberculosis or hepatitis infection, which is why you'll be screened for that before you begin treatment. There's also a small increased risk of lymphoma, says Dr. Zeichner. Finally, some biologics may be associated with the development of inflammatory bowel disease or certain neurological conditions.
“Despite these potential risks, these drugs are very safe and effective and in fact, are safer than many of the traditional medications used to suppress the immune system and treat psoriasis,” Dr. Zeichner adds. These medications--methotrexate and cyclosporine--can have significant side effects, including kidney and liver damage. Cyclosporine, specifically, can cause blood clots in the kidneys.
Always contact your doctor if you experience any sign of infection, whether respiratory, skin or otherwise, Dr. Zeichner says. You should speak to your doctor if you have HIV, hepatitis, or are on chemotherapy, as some medications cannot be used in these circumstances.
How Do You Know If a Biologic Is Right for You?
Biologics aren’t for everyone. It’s important for your doctor to consider how well you respond to other forms of treatment, how much psoriasis affects your quality of life, and what the potential risks of treatment might be. Your personal health is important to consider, as well.
Dr. Zeichner typically looks at psoriasis patients in two categories. “Either you are a candidate for topical treatments, or you are a candidate for more than topical treatments,” he explains. If you want more than just topicals, biologics may be an appropriate first-line treatment, he says. “But it is important for you to discuss your condition with your doctor so you can make a decision together,” Dr. Zeichner says.
Biologics might not be best for people with a history of cancer, infection or a weakened immune system. If topical treatments and oral systemic treatments like methotrexate and cyclosporine do not work for you, says Dr. Sobel, your dermatologist will then work with you to determine if you are a good candidate for biologics. “They’ll determine the right biologic for you based on the severity, the percentage of body surface area affected, whether psoriatic arthritis is involved, and any particular forms of psoriasis that are hard to treat,” he adds. “If you are not reacting well to one form where your symptoms are lessening, your dermatologist may switch to another form.”
How Can I Tell If Biologics Are Working?
Dr. Sobel says that you will notice a decrease in psoriasis plaques and see clear skin within a few weeks. Zeichner agrees: “If you start a biologic, hopefully, you should start to see improvement in the skin within two or three weeks. In some cases, it may take longer,” he notes.
How Is Treatment Monitored?
You will need to take a blood test every few months to make sure your liver function and blood counts are normal, Dr. Zeichner says. Some treatments are administered at an infusion center via IV drips and some are at-home injections that patients can self-administer, Dr. Sobel says. Dosing schedules vary but can range from once a week to one every three months, according to the American Academy of Dermatology. Normal follow-up visits to monitor any changes are required. “I typically see patients back three months after starting a new drug and every six months after that,” says Dr. Zeichner.
Do Insurance Companies Cover Biologic Treatments?
Are you ready for good news and bad news? The bad news is that biologics are very expensive so your insurance company will likely want your doctor to try other less expensive treatments first. The good news is that if those treatments don’t work, then your insurance company likely will cover the cost of a biologic.