What to Know About Biologics for Psoriasis

Biologic medication refers to any type of medication that is derived from living organisms. Biologic medication used to treat psoriasis comes in injection or infusion form. The medication targets certain antibodies, proteins produced by the immune system to counteract certain pathogens, to reduce autoimmune processes that cause inflammatory skin symptoms of psoriasis. 

Uses

Biologic medication is approved by the U.S. Food and Drug Administration (FDA) to treat psoriasis and other inflammatory, autoimmune conditions, where the immune system attacks healthy cells by mistake. Autoimmune conditions produce widespread inflammation throughout the body, causing elevated levels of cytokines, or inflammatory proteins. 

With psoriasis, the most commonly elevated cytokines include tumor necrosis factor (TNF)-α, interleukin(IL)-17, and interleukin(IL)-23. Biologic medications are categorized into three different classes based on which cytokine they target:

• TNF-α inhibitors, such as Humira (adalimumab), Cimzia (certolizumab pegol), Enbrel (etanercept), and Remicade (infliximab). Simponi (golimumab) is another TNF-α inhibitor used specifically for treating psoriatic arthritis, an inflammatory form of arthritis that affects some people with psoriasis.
• IL-17 inhibitors, such as Siliq (brodalumab), Taltz (ixekizumab), and Cosentyx (secukinumab).
• IL-23 inhibitors, such as Tremfya (guselkumab) and Skyrizi (risankizumab). Stelara (ustekinumab) is also a biologic medication classified as both an IL-23 and IL-12 inhibitor.

According to several randomized control trials, the IL-17 inhibitor brodalumab may be more effective than other medications for improving symptoms of psoriasis, while the TNF-α inhibitor etanercept has the lowest efficacy in improving long-term outcomes.

Biologic medication may also be able to improve other medical conditions related to psoriasis and autoimmune conditions, such as reducing the risk of depression and accumulation of coronary artery plaque (fatty deposit), thereby reducing the risk of heart attack and stroke.

Before Taking

Before taking any biologic medication, you should always have your doctor do a thorough medical examination and discuss your symptoms and medical history. Your doctor will then decide if the benefits of taking biologic medication for psoriasis outweigh the potential risks. Biologic medication is usually well tolerated with few adverse side effects.

Because biologic medication suppresses your immune system, live vaccines that contain live viral components are typically avoided. You may need to get certain vaccines, such as tuberculosis or hepatitis B, before starting biologic medications.

Because biologics are often expensive and more invasive than other types of medications, they are often prescribed after you have already tried other medications such as oral steroids.

Precautions and Contraindications

Because biologic medications can suppress your immune system, there is concern that they can potentially suppress the immune system of developing babies in pregnant people. Certolizumab is recommended for pregnant people with psoriasis because of its reduced likelihood of transfer to a developing baby, followed by etanercept.

Currently, etanercept is the only biologic medication approved for treating children with psoriasis who are over 6 years old. Some biologic medications, however, are being used off-label for treating psoriasis in children. TNF-α inhibitors are generally safe and effective for managing symptoms of psoriasis in pediatric patients.

Because biologic medication suppresses your immune system, it can be challenging to treat patients with psoriasis who also have chronic infections, such as hepatitis B, HIV, and latent tuberculosis, because they are already immunocompromised.

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During the acute stage of a hepatitis B infection, patients should not be treated with biologics, although it can be initiated once the infection has resolved under close monitoring. TNF-α inhibitors may lead to reactivation of the hepatitis B virus, but IL-17 inhibitors may be a safer option when treatment is monitored closely.

For patients with HIV, biologics may be used with caution, but these patients should be closely monitored. IL-17 inhibitors for the treatment of psoriasis are generally safe for people with latent tuberculosis. However, treatment with TNF-α inhibitors can be used only after one month of preventative tuberculosis treatment has been completed.

Dosage

Most biologic medications are delivered through an injection, which is often performed by yourself. The dosage of medication in each syringe or auto-injector will depend on the manufacturer. The only biologic medication that is not delivered through injection is Remicade, which is delivered intravenously (IV), inserted into a vein in your arm, at a hospital or infusion center.

Modifications

Make sure to discuss the benefits and risks of taking biologic medication with your doctor. Certain types of biologic medications for treating psoriasis are safer and more effective in certain patient populations, including pregnant people, children, and those with compromised immune systems or chronic infections, such as HIV, tuberculosis, and hepatitis B.

How to Take and Store

Your biologic medication should be refrigerated before use. Remove your medication 30 minutes before the time that you are going to administer your injection so that the medication can reach room temperature.

Before you administer your injection, you should have an alcohol pad and sterile bandage ready. Wash your hands with soap and water, and swab the skin where you will administer the injection with an alcohol pad to cleanse the skin and reduce the risk of infection.

The frequency of injections depends on the specific type of medication that you are prescribed. Remicade is delivered intravenously through insertion of an IV into a vein and repeated every eight weeks.

All the other types of biologic medications are injected subcutaneously, or under the skin, most commonly in your abdomen or thigh. Some medications require a frequent injection schedule, such as Enbrel every week and Humira, Siliq, and Cimzia every other week.

Other medications require less frequent injections after the initial dose, such as Cosentyx and Taltz every four weeks, Simponi once a month, Tremfya every eight weeks, and Skyrizi and Stelara every 12 weeks.

Side Effects

The most common adverse drug reactions associated with biologic injections include pain, swelling, itching, rash, and redness at the injection site. If you have any of these symptoms, talk with your doctor about the possibility of switching your medication type.

Sometimes paradoxical reactions can occur in which psoriasis symptoms actually worsen or flare up with biologic medication, especially TNF-α inhibitors, although the symptoms are usually not severe enough to stop taking the medication.

IL-17 inhibitors have not been around for a long time, so there are less data regarding their safety, although research so far suggests that they are well tolerated with minimal side effects. IL-17 inhibitors can increase the risk of candidiasis, or yeast infection, although these infections usually are not severe enough to stop treatment with IL-17 inhibitors. Rare side effects reported with use of IL-17 inhibitors include neutropenia, low levels of the white blood cell neutrophil, and inflammatory bowel disease.

Because biologic medications decrease your immune system's response to reduce inflammation from autoimmune reactions, it can also increase your risk of acquiring an infection or reactivating a prior infection such as hepatitis B or tuberculosis. Tuberculosis screening through skin testing, interferon (IFN)-c-release assay, chest X-ray, and chest CT (computed tomography) scan is recommended before starting biologic medications and during treatment to monitor for tuberculosis risk.

Warnings and Interactions

You should always be under the care of a physician when taking a biologic medication and follow your dosage scheduling as prescribed.

Manufacturers warn that the biggest risk of taking biologic medications is the possibility of infection due to suppression of your immune system. Because of this, live vaccines, including the vaccines for influenza and chickenpox, should not be administered while on biologic medication.

While research is still ongoing, there is no evidence so far that suggests biologic medications have drug-to-drug interactions with other medications.

Summary

Biologics can treat psoriasis by suppressing an overactive immune system and slowing down skin cell growth. Because of this, while biologics are effective treatments for psoriasis, they also come with an increased risk of infections due to immunosuppression. Your doctor will therefore prescribe biologics only if steroids and other treatments fail to help. Biologics are typically injected and you can administer the medication at home.

A Word From Verywell 

While costly, biologic medication can be a safe and effective treatment option for managing symptoms of psoriasis when other treatment options have failed. This type of medication is not a cure for psoriasis, but it can significantly reduce inflammation, and improve your psoriasis symptoms and overall quality of life.

Make sure to discuss the benefits and risks of biologic medication with your doctor to determine if this treatment is right for you.