Best Biologic PsA Skin — SCE Rheumatology MCQ

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ModerateSpondyloarthropathyBest Biologic PsA SkinSCE Rheumatology

A 55-year-old man has active peripheral psoriatic arthritis and extensive plaque psoriasis despite an adequate trial of methotrexate. His psoriasis is the disease domain causing the greatest impairment. He has no inflammatory bowel disease, recurrent uveitis or contraindication to biologic therapy. Which treatment mechanism should be prioritised to maximise the likelihood of near-complete skin clearance while also treating his psoriatic arthritis?

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Correct answer: B — IL-17 or IL-23 inhibition

Explanation lettering: D = shown as A · E = shown as B · B = shown as D · A = shown as E

E is correct. PsA therapy should be chosen according to the dominant disease domain. For clinically important psoriasis, UK BSR guidance supports preferential consideration of IL-17 or IL-23 pathway inhibition, and current EULAR guidance similarly directs treatment towards IL-17 or IL-23-targeted biologics when skin disease is relevant. These classes offer the greatest likelihood of high-level cutaneous responses, including near-complete clearance, while treating peripheral PsA. TNF inhibitors are effective across several PsA domains but are not the preferred class when maximising skin clearance is the principal objective. IL-12/23 inhibition can improve psoriasis but is generally less effective for very high skin-clearance responses than selective IL-17 or IL-23 inhibition. Abatacept and JAK inhibitors can treat peripheral arthritis but are not preferred specifically for maximal psoriasis clearance. Inflammatory bowel disease would favour avoiding IL-17 inhibition and may influence selection within the correct class.

Reference: Tucker L et al. Executive summary: The 2022 British Society for Rheumatology guideline for the treatment of psoriatic arthritis with biologic and targeted synthetic DMARDs. Rheumatology (Oxford), 2022. https://pubmed.ncbi.nlm.nih.gov/35640653/