Initiating Biologic Therapy: Why IL-23 Inhibitors Are Leading the Way

The decision to initiate biologic therapy in psoriasis is driven by a combination of clinical and patient-centered considerations. Key criteria include whether a patient is achieving meaningful and sustained skin clearance on topical agents, whether the topical regimen has become too burdensome, and whether high-impact areas such as the face, scalp, or genitals are affected. When these thresholds are met, the transition to biologics has become the preferred pathway for many clinicians.

The IL-23 class has emerged as a natural entry point into biologic therapy in large part because of how straightforward it is to discuss with patients. Unlike some other classes, IL-23 inhibitors carry no requirement for routine laboratory monitoring, and there are no meaningful signals for malignancy, depression, inflammatory bowel disease, or reactivation of latent tuberculosis. This clean safety profile allows clinicians to have efficient, reassuring conversations with patients, reducing the concern and hesitation that often accompany the initiation of systemic therapy.

Real-world registry data reflect this trend, with IL-23 and IL-12/23 inhibitors accounting for more than half of biologic initiations in data published at Winter Clinical Hawaii 2026. For patients with psoriatic arthritis—a common comorbidity—2 of the 3 major IL-23 agents carry relevant indications, making them clinically versatile choices. While the IL-17 class may offer superior efficacy for more aggressive psoriatic arthritis, the additional nuances in safety communication required for IL-17 inhibitors—including candidiasis risk and label language around liver function and suicidal ideation—have led many prescribers to favor IL-23 agents as first-line biologics for the majority of their patients.

References

1. Lockshin B, Beeghly A, Blachley T, Eliot M, Barghout V, Mathew J, Ferro T, Prajapati VH. Real-world tildrakizumab persistence in the US by biologic experience and insurance coverage in the PPD CorEvitas Psoriasis Registry. Poster presented at: Winter Clinical Dermatology Conference; January 16-21, 2026; Maui, Hawaii.

2. Prajapati VH, Blachley T, Eliot M, et al. Regional differences in patient characteristics among US biologic initiators from the PPD CorEvitas Psoriasis Registry. Poster presented at: Winter Clinical Dermatology Conference; January 16-21, 2026; Maui, Hawaii.