Clinical Tips for Managing Moderate to Severe Psoriasis With Systemics

“Your word is what they remember. How many times do you remember exactly what you said to every patient, every all day, right?” said Cory Rubin, MD, at a recent Dermatology Times Case-Based Roundtable event.

Rubin, a board-certified dermatologist and founder of the Michigan Dermatology Institute, presented to an engaged room of dermatology clinicians on real-world strategies for optimizing systemic therapy in patients with moderate to severe psoriasis. Through 3 case studies, the discussion demonstrated the continued evolution of biologic use, treatment sequencing, and shared decision-making in chronic plaque psoriasis.

Case 1: Rapid Control and Convenience With Bimekizumab

A 40-year-old man with psoriasis involving the scalp, arms, and lower legs (approximately 10% body surface area [BSA]) presented with moderate pruritus and limited availability for follow-up visits due to his outdoor occupation. The roundtable group agreed that this patient would benefit from a systemic biologic that offers both efficacy and practicality. Bimekizumab (Bimzelx; UCB), an IL-17A/F inhibitor, was selected for its rapid onset of action and durable control, with dosing every 8 weeks aligning with the patient’s lifestyle.

“Bimekizumab is one of, if not the only biologic, without a true loading dose,” Rubin said. He went on to explain that some patients may even stay on an every 4-week dosing schedule to achieve clear or almost clear skin.

Rubin noted that in similar cases, balancing treatment efficacy with convenience can be key to adherence. The group emphasized that systemic escalation should be guided by objective measures such as PASI, BSA, and quality-of-life indices, particularly when topical therapies prove inadequate for difficult-to-treat areas such as the scalp or lower extremities. Monitoring for oral candidiasis and other adverse effects remains essential throughout therapy.

When discussing patient education and conversations regarding systemic use, the attendees all agreed that they give their patients the autonomy to choose their treatment, but they do provide their clinical expertise on what they think will work best.

“I tell my patients, ‘If it were me or somebody in my family, this is the drug I would use, here’s why, and here are the other options,’” said an attendee.

Case 2: Managing Nail Disease and Psoriatic Arthritis Risk

The second case involved a 42-year-old man with plaque psoriasis and nail involvement, reporting worsening pitting and onycholysis after a waning response to ustekinumab (Stelara; Janssen). With 8% BSA and a family history of ulcerative colitis, the patient’s case highlighted the importance of mechanism selection and safety considerations.

The roundtable group opted for risankizumab (Skyrizi; AbbVie), an IL-23 inhibitor with efficacy in both cutaneous and nail psoriasis, offering a 12-week dosing schedule suited to patient preference. Rubin noted that nail disease often reflects deeper inflammatory activity and may signal a higher risk for psoriatic arthritis (PsA), warranting early systemic intervention.

“I like the safety of the IL-23s. You can tell your patients that they’re not going to have any adverse effects,” said an attendee.

Routine follow-up incorporating PASI and Nail Psoriasis Severity Index scoring allows clinicians to track progress objectively, while ongoing dialogue about comorbidities ensures therapy aligns with the broader health profile.

Case 3: Addressing Refractory Scalp Psoriasis and Incomplete Biologic Response

The final case featured a 49-year-old woman with chronic scalp and elbow psoriasis who reported intense itch and suboptimal response to secukinumab (Cosentyx; Novartis) after 18 months of therapy. The group’s discussion centered on strategies to improve disease control, including dose escalation, adjunctive topicals, or switching biologic classes.

When response remains partial, Rubin and colleagues advised considering mechanistic differentiation, such as transitioning from an IL-17A inhibitor to a dual IL-17A/F inhibitor, such as bimekizumab or to an IL-23 inhibitor for broader modulation. The scalp’s thick stratum corneum and localized inflammation make it a notoriously challenging site, often necessitating potent or faster-acting biologics.

“Some people like having a backup,” said one attendee. “I may start with an IL-17A. If it works, that’s great. If not, I have bimekizumab as a backup.”

The group also discussed the importance of assessing the psychological burden associated with chronic visible disease, recommending referral for mental health support when appropriate.

Practice Insights

Across the 3 cases, several key principles for systemic management of moderate to severe psoriasis emerged:

• Regular Monitoring: Treatment efficacy should be measured through PASI and IGA assessments, with early recognition of adverse events such as candidiasis or upper respiratory infections.
• Mechanistic Understanding: Familiarity with cytokine pathways—IL-17A/F vs IL-23 inhibition—supports more strategic initial selection and informed switching.
• Patient-Centered Care: Incorporating lifestyle, work constraints, and treatment preferences into therapy decisions enhances adherence and satisfaction.
• Defined Escalation Pathways: Clear criteria for treatment failure and structured switching protocols after 3 months prevent prolonged disease activity and improve long-term outcomes.

Rubin concluded that as systemic options expand, precision in therapy selection is increasingly achievable. By pairing objective assessment tools with patient-specific factors, dermatologists can better deliver durable clearance and improved quality of life for individuals living with psoriasis.