As biologics multiply, the boundary between topical failure and systemic eligibility remains contested. Dr. Armstrong outlines the severity thresholds, comorbidities, and quality-of-life factors that most reliably justify escalating plaque psoriasis therapy.
A systemic-naive roofer with extensive plaque psoriasis and cardiometabolic risk illustrates why compliance history, not just disease severity, should shape the first conversation about moving beyond topical therapy.
With more biologic classes available than ever, selecting a first-line agent for a treatment-naive patient increasingly depends on comorbidity screening, lifestyle fit, and realistic expectations rather than efficacy data alone.
Speed of onset and long-term durability are often treated as competing priorities. Dr. Armstrong argues they are not mutually exclusive, and details how cardiometabolic comorbidities and how emerging incretin-therapy data may extend treatment options beyond skin clearance alone.
