Plaque Psoriasis Treatment: When to Escalate From Topical to Systemic Therapy

Welcome back to another Dermatology Times Case-Based Peer Perspectives series. In "Plaque Psoriasis Treatment: When to Escalate From Topical to Systemic Therapy," moderator Christopher Bunick, MD is joined by April Armstrong, MD to open the series on plaque psoriasis.

Dr. Armstrong opens by outlining current benchmarks for escalating plaque psoriasis from topical to systemic therapy. She cites moderate-to-severe disease, typically defined as body surface area of 10% or greater, as one qualifying threshold. She also flags high-impact sites, including palms, soles, nails, scalp, and genital regions, as independent triggers for escalation regardless of overall body surface area. Armstrong references updated International Psoriasis Council guidance recognizing patients inadequately controlled on topical therapy as systemic candidates, even without meeting the body-surface-area threshold. Dr. Bunick highlights the IPC's specific definition of topical failure: two four-week trials of topical therapy without reaching clear or almost clear. Armstrong notes this criterion, while clinically sound, is often aspirational because payers rarely recognize it for prescribing approval. She emphasizes that quality-of-life impact ultimately drives her escalation decisions more than any single checklist item.

The panel then turns to patient characteristics beyond severity that shape therapy selection. Armstrong walks through several comorbidities she screens for systematically. Psoriatic arthritis, even with minimal skin involvement, pushes her toward a systemic therapy that addresses joints and skin together. Cardiometabolic disease and inflammatory bowel disease also narrow her choices, since IL-17 inhibitors are typically avoided in patients with Crohn's disease or ulcerative colitis. She asks every patient of childbearing potential about pregnancy plans to anticipate future treatment needs. On congestive heart failure, Armstrong explains that older concerns tied to TNF inhibitors have not held up in real-world IL-17 and IL-23 data. She reports that cancer recurrence rates in patients on these newer biologics appear comparable to the general population for solid tumors, though she treats leukemia and lymphoma histories more cautiously alongside oncology colleagues.

The next episode in this series, "Case 1: Assessing a Systemic-Naive Patient With Occupational Plaque Psoriasis," introduces the panel's first patient case, a systemic-naive roofer whose occupation and cardiometabolic risk complicate his treatment path.