While topical creams and ointments can clear up mild to moderate cases of psoriasis, severe cases call for systemic medications that can alter the immune system and target key producers of inflammation. Until a few years ago, conventional medications like methotrexate, cyclosporin, acitretin and hydroxycarbamide were the only systemic therapies prescribed to suppress the immune system and clear up severe psoriasis. However, in recent years, drugs referred to as biologics have been approved to treat psoriasis. Dermatologist and surgeon David T. Harvey, MD, of Piedmont Healthcare, discusses the most common questions his patients have about biologics. 1. Q: What are biologics and how do they work? A: Biologics work at the cellular level to block inflammation and the rapid production of skin cells that cause psoriasis. All of the biologics that treat psoriasis, like etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), secukinumab (Cosentyx) and ustekinumab (Stelara), are administered by injection or IV infusion. Each of these agents works differently, but they all target and modify specific pathways that induce skin inflammation. Right now is an exciting time, because as we learn more about the nature of psoriasis on a cellular level, we can get a better feel of which targets to focus on and what type of biologic to develop. 2. Q: What side effects are associated with biologics? A: Since biologics impact our immune system, there’s an increased risk of infection when you are on these medications. That’s why patients must be tested for tuberculosis before starting them. We’ll also assess a patient’s baseline cancer status and hepatitis risk, because the biologics can affect these areas as well. In general, I don’t encounter that many problems with these medicines; most patients tolerate them pretty well. Rarely, patients can experience flu-like symptoms or injection site pain, but these adverse reactions are temporary and mild in nature. 3. Q: How do you decide it’s time to try a biologic? A: If a patient isn’t getting better with topical agents or is not tolerating traditional systemic therapies like methotrexate, then I’ll look to the biologics. I’ll also pull the trigger pretty quickly if the psoriasis plaques are painful or if a patient is experiencing joint pain from psoriatic arthritis. Sometimes insurance companies will make our patients try other treatments first before paying for biologic medications due to their expense, so even if I feel it’s the best option, we may have to try other medications first. With respect to the specific biologic brands, insurance companies will often dictate to us what type of biologic medicine they’ll pay for. If all options are on the table, then I will decide which biologic to use based on the patient’s symptoms and preferences. For example, if a patient has severe joint pain accompanying his or her psoriasis, I’ll probably recommend a TNF-inhibitor like adalimumab (Humira) administered every other week. TNF stands for Tumor Necrosis Factor. Patients with psoriasis and psoriatic arthritis have too much TNF in their skin and joints. TNF-inhibitors lower the amount of TNF in these areas, which improves the patient’s symptoms from psoriasis and psoriatic arthritis. For those who don’t want to come in for injections every other week, I might prescribe ustekinumab (Stelara) because that’s administered every 90 days. I make the patient an active participant in this decision, because I want to make sure they’re going to be compliant with my recommendations. 4. Q: Do patients have success with biologics? A: I see significant success with the biologics. They are well tolerated and patients tend to be good about their compliance with the injection schedule. With close monitoring, I’d say 80 to 90% of my patients do well on these medications. 5. Q: What do you wish your patients knew about treating psoriasis with biologics? A: I want them to know that we can manage their disease even though there is no cure. I warn them against stopping these meds prematurely when their psoriasis is properly managed because the disease is something that’s always going to be there, even though it’s under control. We may be able to lower your medication dosage, but the number one thing to do is stay consistent with your treatment and monitoring visits.