Psoriasis Treatment in 2025: More Options, Better Outcomes

psoriasis drug choices
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This past May, I presented the “Updates in Psoriasis” lecture and chaired the medical dermatology session at a large international meeting in Lisbon, Portugal. During my talk, I saw some glossed over eyes and head shaking. I stopped and asked the audience, “Do you even have these medications?” The answer was, “No.” Some countries are still using methotrexate as a first-line systemic agent and do not have any of the new topical PDE4 inhibitors or aryl hydrocarbon receptor agonist drugs, opting instead for long-term topical steroid or vitamin D analogs. In the United States, by contrast, we are relying less on TNF-alpha inhibitors and have moved on to IL-23, IL-17 A/F, and JAK inhibitors, among others. We have better drugs to treat psoriasis than almost any other dermatologic disease state. For patients, it is an excellent time to have psoriasis.

Apremilast

Otezla® (apremilast) is an oral PDE4 Inhibitor that has been available for years and has always been indicated for psoriatic arthritis (PsA) but is now indicated for all types of psoriasis, mild to severe. A pediatric psoriasis indication also was added recently for patients 6 and older who weigh more than 20 kg and are candidates for systemic therapy. My practice was involved in clinical trials for the use of this drug to treat genital psoriasis. The benefits of this oral systemic therapy, which is not as powerful as other systemic drugs, include the fact that no laboratory testing is required and, although not explicitly indicated as an add-on therapy, it can be used with other classes of systemics due to its unique mechanism of action (MOA), which reduces inflammation but may cause nausea, gastrointestinal issues, and weight loss. I like apremilast as an initial therapy for someone who doesn’t want to do laboratory testing or is needle averse. I also use it as an add-on therapy for joint pain or clearance when not clear on a biologic.

Roflumilast

Zoryve® 0.3% (roflumilast) is indicated for plaque psoriasis in the cream version for ages 6 and above and in the 0.3% foam version for the scalp and body psoriasis in patients 12 and above. It is propylene glycol-free, which is great for our allergic patients. There is also a 0.15% cream version for patients with atopic eczema. The DERMIS-1 and DERMIS-2 studies showed roflumilast use resulting in 72% of patients reaching PASI 50, 40% achieving PASI 75, and 50% being clear or almost clear at 8 weeks.1

Tildrakizumab, Risankizumab, and Guselkumab

Although not new, Ilumya® (tildrakizumab-asmn) is an injectable buy-and-bill therapy for patients with moderate-to-severe plaque psoriasis who are looking to use their medical benefits instead of pharmacy benefits to pay for their medication with Medicare Part B. As physicians, waiting for payment after buying the product and billing the insurance can be a heart-wrenching prospect. Although tildrakizumab is not indicated for PsA, the other IL-23 class drugs are. In the UltIMMa studies, Skyrizi® (risankizumab-rzaa) had 75% PASI 90 at 16 weeks,2 but efficacy through 6 years of follow-up was between 85% and 90% with the drug being dosed every 3 months.3 In the VOYAGE studies, Tremfya® (guselkumab) had at least 84% of patients clear or almost clear at 16 weeks.4 The IL-23 class works great for psoriasis with both risankizumab and guselkumab being indicated for PsA, ulcerative colitis, and Crohn’s disease, so there is no need to worry about inflammatory bowel disease (IBD) affecting treatment.

Bimekizumab 

The IL-23 drugs are higher up in the inflammatory pathway cascade than the IL-17 therapies, and Bimzelx® (bimekizumab-bkzx) is an IL-17 A/F inhibitor whose MOA includes blockage of IL-23-independent pathways. Its indications include psoriasis, PsA, ankylosing spondylitis, and hidradenitis suppurativa. As a result of its unique MOA, warnings include oral candidiasis and suicidal ideation, and the drug cannot be used in patients with active IBD. Updates to bimekizumab include its BE OPTIMAL study in which biologic-naïve patients (who can still be on methotrexate) at 2 years showed tremendous American College of Rheumatology (ACR) score improvements.5 I like this newest IL-17 drug for patients without IBD who want quick onset and great results.

Tapinarof Cream

Vtama® (tapinarof) cream, 1% is an aryl hydrocarbon receptor agonist indicated for the topical treatment of plaque psoriasis in adults and atopic eczema to age 2. The drug helps to repair the skin barrier by increasing filaggrin, loricrin, and involucrin, while decreasing inflammation by reducing Th17 and thereby IL-17 A/F. Its unique MOA makes tapinarof cream, 1% a great standalone or add-on therapy to systemic agents, boasting 4 months of remittive therapy when patients are clear or almost clear post-treatment. In the PSOARING 3 trial, 40.9% of patients achieved complete disease clearance.6 Because it’s not a steroid, the associated side effects are different—in this case, most notably folliculitis (seen less frequently in atopic patients).

Upadacitinib and Deucravacitinib

Rinvoq® (upadacitinib) is a JAK-1 inhibitor and has multiple indications (as do IL-23 inhibitors) but has not yet been approved for psoriasis. In my experience, upadacitinib does improve psoriasis when written for its PsA indication.

Similar to the JAK therapies is a relatively new oral TYK2 inhibitor, Sotyktu® (deucravacitinib). It does not carry the same black box warning for major adverse cardiovascular events (MACE) as the JAK inhibitors do, due to its different binding site on the JAK-STAT pathway (no MACE were observed in the clinical trials). Like all biologics for psoriasis, deucravacitinib requires a tuberculosis test. Respectable efficacy was demonstrated in its POETYK trials, showing 49.5% of patients becoming clear or almost clear within 16 weeks.7 It is especially good for patients not interested in a shot.

Spesolimab for GPP

The anti-IL-36 monoclonal antibody Spevigo® (spesolimab-sbzo) is indicated for generalized pustular psoriasis (GPP). In trials, 54% of GPP patients had no pustules after 1 week.8 GPP is extraordinarily rare, but spesolimab is available, efficacious, and dosed monthly without the need for any testing.

While it is impossible to go into detail on every psoriasis drug and each new indication, dermatologists should be aware of the fantastic psoriasis treatments available to us and our patients now that were non-existent 20 years ago. These new drugs may not yet be available in other parts of the world, but they are worth exploring  as we look to minimize side effects and improve efficacy. 

References

1. Lebwohl MG, Kircik LH, et al. Effect of roflumilast cream vs vehicle cream on chronic plaque psoriasis: the DERMIS-1 and DERMIS-2 randomized clinical trials. JAMA. 2022;328(11):1073-1084. https://doi.org/10.1001/jama.2022.15632

2. Odnopozova L, Edin A, et al. Risankizumab for the treatment of moderate to severe plaque psoriasis in the Russian Federation. Dermatol Ther(Heidelb). 2022;12(9):2063-2075. https://doi.org/10.1007/s13555-022-00776-0

3. Papp KA, Lebwohl MG, et al. Long-term safety and efficacy of risankizumab to treat moderate-to-severe plaque psoriasis: final LIMMitless phase 3, open-label extension trial results. Am J Clin Dermatol. 2025. https://doi.org/10.1007/s40257-025-00964-6

4. Reich K, Armstrong AW, et al. Efficacy and safety of guselkumab, an anti–interleukin-23 monoclonal antibody, compared with adalimumab for the treatment of patients with moderate to severe psoriasis with randomized withdrawal and retreatment: results from the phase III, double-blind, placebo- and active comparator-controlled VOYAGE 2 trial. J Am Acad Dermatol. 2017;76(3):418-431. https://doi.org/10.1016/j.jaad.2016.11.042

5. Mease PJ, Merola JF, et al. Safety and efficacy of bimekizumab in patients with psoriatic arthritis: 2-year results from two phase 3 studies. Rheumatol Ther. 2024;11(5):1363-1382. https://doi.org/10.1007/s40744-024-00708-8

6. Strober B, Stein Gold L, et al. One-year safety and efficacy of tapinarof cream for the treatment of plaque psoriasis: results from the PSOARING 3 trial. J Am Acad Dermatol. 2022;87(4):800-806. https://doi.org/10.1016/j.jaad.2022.06.1171

7. Strober B, Thaçi D, et al. Deucravacitinib versus placebo and apremilast in moderate to severe plaque psoriasis: efficacy and safety results from the 52-week, randomized, double-blinded, phase 3 Program fOr Evaluation of TYK2 inhibitor psoriasis second trial. J Am Acad Dermatol. 2023;88(1):40-51. https://doi.org/10.1016/j.jaad.2022.08.061

8. Spesolimab for generalised pustular psoriasis. Aust Prescr. 2025;48(3):109-110. https://doi.org/10.18773/austprescr.2025.025

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