Use of biologic therapeutics in difficult-to-treat psoriasis

A need for improved psoriasis management drove the development of four biologicals now approved for use in moderate to severe psoriasis: alefacept, efalizumab, etanercept, and infliximab.

This review compares the recommended and practical use of biologicals in "difficult-to-treat" psoriasis. Difficult-to-treat patients, a subpopulation of particular interest to caregivers and regulators, are those for whom conventional options are unavailable, contraindicated, intolerable, or ineffective.

Despite guidance recommending that biologicals be considered among first-line antipsoriasis treatments, formulary inclusion may be influenced by the biologicals' success in controlling difficult-to-treat psoriasis. Findings from the Clinical Experience Acquired with Raptiva (CLEAR) randomized controlled trial (RCT) established efalizumab's equal efficacy in difficult-to-treat and moderate to severe psoriasis. The CLEAR data were cited in support of a regulatory recommendation to include efalizumab in Canadian provincial formularies. For some other biologicals, evidence regarding efficacy in difficult-to-treat psoriasis remains equivocal. Additional RCTs are needed to define appropriate roles for specific biologicals in difficult-to-treat patients.