Psoriasis Update: Current State, Pipeline, and More

April W. Armstrong, MD, MPH, has been a driving force behind advancements in psoriasis treatments in recent years. A professor and chief of dermatology at University of California Los Angeles, Dr. Armstrong has served in leadership positions for the National Psoriasis Foundation, International Psoriasis Council, Group for Research and Assessment of Psoriasis and Psoriatic Arthritis, American Academy of Dermatology, and more. She spoke with Practical Dermatology about the present and future of psoriasis treatments—including the possibility of a “cure.”

HOW WOULD YOU DESCRIBE THE CURRENT STATE OF PSORIASIS TREATMENTS?

We are in a transformative era with multiple different therapies that can achieve high levels of skin clearance, and many of them also have rapid onset and long durability. The next wave is enhancing our oral therapies even more. The introduction of oral systemics such as apremilast and deucravacitinib really expanded our options for patients. The bar for oral medications has been raised and we are looking on the horizon to oral IL-23 inhibitors as well as advanced TYK2 inhibitors to see if we can truly bring biologic-like efficacy to our patients with oral medications.

WITH SO MANY BIOLOGIC THERAPIES AVAILABLE THAT ALMOST ANY PATIENT SHOULD BE ABLE TO FIND SOMETHING THAT WORKS FOR THEM, WHAT IS LEFT TO IMPROVE?

It’s mainly two areas. First, can we find the right biologic for the right patient the first time? Sometimes this can be a trial-and-error situation. Some patients we think would respond to one type of biologic end up not responding to that biologic optimally, and we need to switch. How to really get it right the first time is very important. Second, as a field, we are looking to develop medications that are even more infrequently dosed. Currently, our least frequently dosed biologics are every 3 months, but clinical trials are looking at innovations that may lengthen that dose to 6 months. The possibility of controlling the biologic with such infrequent dosing that it is not occupying much of our patient’s head space—logistically, at least—is a good thing.

WHAT ROLE WILL GENETIC TESTING AND ARTIFICIAL INTELLIGENCE (AI) PLAY IN FINDING THE RIGHT BIOLOGIC FOR EACH PATIENT THE FIRST TIME?

There are several different approaches, and some innovations already are on the market. For example, you can send a sample of the top layer of skin to a laboratory that tests it against thousands of biomarkers to inform the decision on which class of biologics may be best for that patient. These technologies are continually being validated, and other efforts are ongoing to see how they can be reimbursed by insurance companies. While these options are not yet widespread, they can be especially useful  for patients with more difficult-to-treat psoriasis who have already tried several biologics. There are also concurrent efforts looking at how augmented intelligence can be utilized to analyze various clinical factors to better predict which biologic may work best for each patient. That has been attempted for a long time, but has always been a more isolated investigative effort. With augmented intelligence, we’re able to combine various elements from the patient’s clinical profile and make (hopefully) a more accurate prediction.

HOW MUCH PROGRESS IS BEING MADE IN TREATING PSORIASIS IN SKIN OF COLOR?

There is growing awareness and progress is being made, but we have more work to do. The clinical trials increasingly aim to recruit more diverse patient populations, which is very important to understanding the efficacy, safety, and presentation across all skin types. Some skin conditions will have a predilection for certain skin types, so we do recognize that as well. Ensuring that the clinical trials reflect the real-world prevalence is also important. Recruiting the patient populations that are typically underrepresented in the clinical trials will provide us with important knowledge that will enable us to better care for everyone in clinical practice.

WILL THERE EVER BE A “CURE” FOR PSORIASIS OR IS 6-MONTH DOSING REALISTICALLY THE CLOSEST WE CAN GET TO THAT?

It depends on the person. As we have already observed through real-world use of biologics, some people can really stretch out the interval between the biologics. Most people cannot do it as far as 6 months without seeing a recurrence of disease, but we are getting there. If we can stretch dosing to 6 months or even a year in the future, we will be talking about biologics having frequency similar to vaccines. As long as the safety profiles of these biologics remain favorable, some would argue that this would bring us close to a functional cure for our patients. I know that multiple ongoing research efforts are looking at this—not just looking at the frequency of injection itself but also changes in biomarkers fundamentally in the patient. All of these efforts will continue to advance toward what we can consider at least a functional cure for our patients.

SHOULD PSORIATIC ARTHRITIS BECOME EXCEEDINGLY RARE AS MORE PEOPLE ARE TREATED MORE QUICKLY AND EFFECTIVELY?

This is an important and forward-looking question—one that our group has explored through independent epidemiologic studies. There is growing reason to believe that if patients with psoriasis are treated early with systemic agents that address both cutaneous and joint disease, we may begin to see a meaningful reduction in the incidence of psoriatic arthritis. At the very least, early and effective intervention may prevent patients from progressing to the most severe, deforming forms of the disease, such as arthritis mutilans.

The idea of intercepting psoriatic arthritis before it fully manifests—or even preventing it altogether—is gaining traction in the field. Of course, this strategy depends on the availability of therapies with good safety profiles, particularly for those identified as being at higher risk of developing joint involvement. But with the right tools, early intervention has the potential to alter the disease course dramatically and improve long-term outcomes for many patients.

HOW IMPORTANT IS OUR UNDERSTANDING OF GENETICS AND IMMUNOLOGY, AND HOW QUICKLY ARE DEVELOPMENTS OCCURRING ON THAT FRONT?

Our understanding of genetics and immunology is absolutely foundational to the progress we’ve made in psoriasis—and really, in all inflammatory skin diseases. Most of the advanced therapies we have today exist because we’ve been able to unravel key immune pathways, often through a combination of deep scientific insight and trial and error. That knowledge has revolutionized how we treat these conditions.

Some of the most exciting breakthroughs have come from what could be considered “nature’s experiments.” For instance, researchers identified individuals with naturally diminished TYK2 signaling who didn’t develop psoriasis or inflammatory bowel disease. That kind of observation raised an important question: Could TYK2 be a therapeutic target? Fast-forward to today, where we now have treatments that do just that—target TYK2 to treat psoriasis.

Genetic variation can give us important clues about where the next breakthroughs may lie. Looking ahead, the integration of genomics, clinical phenotype, and biomarker data will become increasingly central to how we diagnose and treat inflammatory skin disease. In oncology, we already see how biomarker-guided therapy is standard practice. I think dermatology is moving in a similar direction—with a focus on individualized, precision medicine to ensure patients receive the treatment that’s best suited to them. The pace of discovery is also accelerating. I truly believe that within a few years, we’ll be using multi-omic tools to both diagnose challenging cases with overlapping features and guide therapy selection from the very beginning. It’s an incredibly exciting time in the field.

WHAT ARE SOME OF THE MOST EXCITING DRUGS OR MECHANISMS OF ACTION IN THE PIPELINE RIGHT NOW FOR PSORIASIS?

There are several developments that I find particularly exciting. One is the emergence of an oral IL-23 receptor inhibitor that’s currently in late-phase development. Based on the disclosed phase 3 data, it appears to offer efficacy on par with biologics, paired with a very favorable safety profile. That’s a significant step forward, especially for patients who prefer oral therapies.

We’re also seeing strong momentum around TYK2 inhibitors, with multiple agents in late-phase development showing impressive efficacy for psoriasis. These will be valuable additions to our therapeutic toolkit.

Beyond that, there’s renewed interest in refining how we target phosphodiesterase type 4 (PDE4), potentially improving tolerability or efficacy. Oral therapies that block IL-17 or the IL-17 receptor, as well as TNF inhibitors, are also advancing, offering more diverse options for oral systemic treatment.

Finally, as we become more confident in targeting key cytokines like IL-17 and IL-23, there’s been a push to optimize biologic therapy, especially in terms of dosing intervals. The goal is to maintain (or even enhance) efficacy while improving patient convenience and maintaining safety. Altogether, these innovations are not just incremental—they’re reshaping how we think about delivering long-term control in psoriasis.