Can New Therapies Redefine Psoriasis Management?

“For too long, the management of psoriasis and other immune-mediated inflammatory diseases has suffered from an acceptance that improvement rather than cure is good enough. Our patients deserve greater ambition,” wrote Christopher E.M. Griffiths, MD, and co-authors in a perspective article published in the Journal of Investigative Dermatology (JID).

After reviewing the current interventions — biologic drugs, advanced therapies, and lifestyle modifications — that can restore immunological homeostasis by counteracting the pathogenic mechanisms of psoriasis, the experts concluded that adopting the approach of early intervention constitutes “a realistic moonshot to achieve cure for psoriasis by 2035.”

Progress in the treatment of psoriasis is undeniable. However, not everything Griffiths and colleagues discuss has come to pass, as Giampiero Girolomoni, MD, explained to Univadis Italy. Girolomoni is a professor of dermatology and head of dermatology at the University of Verona School of Medicine in Verona, Italy.

New Therapies

“In recent years, highly effective drugs have become available for treating psoriasis, particularly those that block interleukin (IL) 17 and IL-23, cytokines that play crucial roles in the disease’s pathogenesis,” said Girolomoni. IL-23 is essential for the survival, proliferation, and function of IL-17-producing T helper lymphocytes. IL-17 is the effector cytokine that causes inflammation and indirectly leads to the proliferation of keratinocytes in psoriasis.

“Drugs that block IL-23 generally have the ability to maintain disease remission with widely spaced injections administered every 2-3 months according to official prescription guidelines. But in a significant proportion of patients, they can be spaced out much more widely — every 4-6 months or even 9 months,” he continued.

“Controlled studies have shown that patients who respond best are those with a shorter disease duration. In all immune-mediated inflammatory diseases, the earlier you act, the easier it is to induce persistent remission. ‘Persistent’ may not mean for life, but for extremely prolonged periods.” Drugs that block IL-23 are more effective in inducing prolonged remissions than those that block IL-17 because IL-23 acts upstream in the pathogenic cascade.

Candidates for Systemic Therapy

In their perspective article, the authors stated that a combined approach should be used to target the factors that initiate and perpetuate chronic inflammation and that “ideally, this would encompass early intervention with biologics, advanced therapeutics, and lifestyle modification in patients within the first year of onset of their disease, whatever the severity.”

So should all patients with psoriasis receive the new drugs? “No, we treat patients who have moderate to severe progression,” said Girolomoni. “Most cases of psoriasis are mild, remain so throughout life, and do not require systemic drugs; ointments are sufficient. However, in 10%-15% of cases, the disease becomes severe within a few years.”

Access to systemic therapies for psoriasis is still challenging. “Often these patients have a very difficult journey, and this is true worldwide, including in developed countries,” Girolomoni explained. “Dermatologists who care for them often hesitate, perhaps because they lack confidence in their decisions or for various other reasons. They wait before starting systemic treatment, wasting precious time: In a patient with moderate to severe psoriasis, there is a very high probability that with effective drugs — especially those acting on IL-23 — prolonged remission can be achieved if intervention occurs within the first 2 years from onset.”

Delays in treatment also occur when patients with psoriasis do not seek out specialized centers but choose local physicians instead for convenience, risking partial responses and inconsistent treatment from multiple dermatologists, Girolomoni noted.

Future Perspectives

The article published in JID describes a series of possible therapeutic strategies for psoriasis based on the most innovative technologies proposed in recent years, including chimeric antigen receptor (CAR) T therapies, gene therapy, and microRNA editing. “These are still rudimentary therapies,” commented Girolomoni, clarifying that they may eventually become part of the arsenal for psoriasis treatment, but that is years away.

As for the prospect of curing psoriasis by 2035, Girolomoni believes that at the moment, “it is as realistic as completely replacing internal combustion engine vehicles with electric cars.” Nevertheless, he shares the conviction of American experts about the need for a change in mindset. “There is still the belief among the general population and primary care physicians that psoriasis cannot be cured and that treatment is pointless because the condition will recur, but with these new drugs we can truly modify the natural course of the disease,” he concluded.

This story was translated from Univadis Italy using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.