Moderate to severe psoriasis has a significant negative impact on quality of life and usually requires lifelong treatment. Treatment options for psoriasis have rapidly expanded in the last decade, with the emergence of therapies that have greater efficacy and more precision in targeting psoriasis. Patients have multiple options now, and they will seek advice from their dermatologist on which option might be best for them. Patients want to know about their options in terms of skin improvement, efficacy, safety, availability, and other aspects such as the number of injections. Payor-related factors also impact treatment. We have various injectable biologics with generally good safety and efficacy profiles that are licensed for moderate to severe plaque psoriasis. These biologics are differentiated in their efficacy, adverse effects, and other important attributes such as dosing frequency.

I focus more on selecting the best treatment for the patient’s skin, and I am less concerned about whether the drug I choose is US Food and Drug Administration approved for psoriatic arthritis, knowing that treatments that reduce psoriatic inflammation in the skin also generally reduce inflammation in the joints. For instance, I am comfortable giving somebody who has psoriasis, along with some arthritis, an interleukin-23 (IL-23) inhibitor to clear their skin, even as a first-line treatment, and then letting their rheumatologist evaluate their joints. I do not measure the range of motion of joints, nor do I know what x-rays to order or how to interpret them, so I will look to the rheumatologist to do that and to ascertain whether the patient might need something different or additional for their joints.

I think that there are many factors to consider when selecting a systemic therapy, but first you need to talk to the patient to determine what their expectations are. You also must understand the patient’s comorbidities. Are they obese? How severe is their disease? How long have they had disease? Do they have inflammatory bowel disease? You also need to determine what their preference might be regarding an injectable vs an oral drug, as well as how often they might be comfortable with self-injecting a drug. I think that talking to the patient and examining them to see how severe their disease is is the best starting point—that is where I begin.

Another factor to consider is the patient’s insurance. Obviously, insurance companies do not pay for every drug. Many patients on Medicare, for example, might do better with a drug that is approved to be covered by Medicare Part B, and tildrakizumab, to my knowledge, is the only drug that falls into that category. There were other IL-23 drugs that were available prior to the US Food and Drug Administration approval of tildrakizumab, but Medicare now excludes them. A benefit of the IL-23 drugs, including tildrakizumab, is the less frequent dosing schedule. Only 4 to 6 injections per year are required, depending on the treatment (eg, it is only 4 per year for tildrakizumab). So, when you tell a patient with a needle phobia that they can be clear and stay clear, and that they only need 1 injection every 2 to 3 months, they might be persuaded to take an injectable.

My approach is to first determine whether we will be using an injectable drug or an oral agent, and then determine whether the therapy has good psoriatic arthritis efficacy. If the patient has psoriatic arthritis, I will often opt for an IL-17 inhibitor because those treatments provide great efficacy and the best arthritis control. If the individual refuses an injectable, then I might recommend apremilast, but, in most instances, I will explain to the patient that the best chance for success is with an injectable.

For those who do not have significant psoriatic arthritis, I am more likely to prescribe an IL-23 inhibitor, which provides great efficacy and an easy dosing schedule, with an every 8- to 12-week interval. Some of the IL-23 inhibitors are effective in the treatment of arthritis as well (eg, guselkumab), but I do not think that guselkumab is as effective as an IL-17 inhibitor or a tumor necrosis factor inhibitor for psoriatic arthritis. The presence of other comorbidities, such as inflammatory bowel disease, will steer you away from IL-17 inhibitors. There is very little that will steer you away from IL-23 inhibitors—there are almost no contraindications—but their one weakness is that they are likely not as good for the psoriatic arthritis.

Patients with plaque psoriasis want to clear their skin in most instances, and the best chance of achieving skin clearance in general is with the injectable drugs. Tildrakizumab is a good drug for patients with Medicare, but those being treated in the outpatient private office setting also must have supplemental commercial insurance, or secondary commercial insurance, to cover the difference. Additionally, patients can get tildrakizumab more easily in hospital settings.