Risankizumab Outperforms Deucravacitinib in Moderate Plaque Psoriasis

The choice between a daily pill and an injection given twice in 4 months is the one biologic-naive patients with moderate psoriasis most often face, and it has been made without head-to-head evidence. In the phase 4 IMMpactful trial (NCT06333860), risankizumab cleared skin in roughly 2.5 times as many patients as deucravacitinib at week 16.¹

A Gap at the Moderate End of the Disease

Deucravacitinib, an oral allosteric inhibitor of tyrosine kinase 2 (TYK2), arrived with strong placebo-controlled evidence: in the phase 3 POETYK PSO-1 trial (NCT03624127), 58.4% of patients taking it reached a 75% reduction in Psoriasis Area and Severity Index (PASI 75) at week 16, against 12.7% on placebo and 35.1% on apremilast (P < .0001).²

Those trials enrolled moderate-to-severe disease and used apremilast as the comparator, leaving the more moderate patient unaddressed. International Psoriasis Council criteria make patients candidates for systemic therapy when body surface area (BSA) involvement exceeds 10%, when sites such as palms, scalp, or genitals are affected, or when topical therapy fails. For them the question is whether to start an oral or go straight to a biologic, and guidelines offered little to decide it.¹

393 Biologic-Naive Adults, Randomized 1:2

IMMpactful is a multicenter, randomized, open-label trial with blinded efficacy assessors, funded by AbbVie, which markets risankizumab. Of 393 patients enrolled, 131 were assigned to risankizumab 150 mg subcutaneously on day 1 and week 4, and 262 to deucravacitinib 6 mg orally daily; 1 patient never received the study drug. Eligibility required stable moderate plaque psoriasis, defined as BSA of 10% to 15%, PASI of at least 12, and sPGA of 3, with no prior biologic exposure.

Mean age was 47.3 years in the risankizumab arm and 44.8 years in the deucravacitinib arm; women made up 38.9% and 37.0%, and psoriatic arthritis was present in 6.9% and 8.4%. Mean baseline PASI was 15.7 and 15.3, mean BSA 13.2% and 13.0%, and mean Dermatology Life Quality Index (DLQI) 12.0 and 11.3, with disease duration averaging 16.1 and 14.1 years. The published results cover only period A, the first 16 weeks of a 52-week protocol; ClinicalTrials.gov now lists the trial as completed, so the week 52 data exist but remain unpublished.

PASI 90 Reached 57.3% vs 22.9%

Both coprimary end points favored risankizumab at week 16, with PASI 90 achieved by 57.3% vs 22.9% and sPGA 0/1 by 80.2% vs 39.7% (P < .0001 for both). The gap widened on the stricter ranked secondary end points, with complete clearance on PASI 100 reached by 27.5% vs 6.5% and sPGA 0 by 27.5% vs 6.9%.

Mean PASI fell 13.4 points (95% CI, 12.6-14.3) with risankizumab against 9.3 points (95% CI, 8.7-10.0) with deucravacitinib, a percentage improvement of 85.7% versus 60.4%. Patient-reported measures tracked the clinical ones: DLQI 0/1, meaning no effect of disease on quality of life, was reached by 64.1% vs 30.5%. On the Treatment Satisfaction Questionnaire for Medication, risankizumab scored higher not only on effectiveness (80.9 vs 62.4) and global satisfaction (87.0 vs 66.5) but also on convenience (87.1 vs 81.5), despite being an injection.

“These results support considering [risankizumab] as a preferred first-line systemic option in patients with moderate psoriasis due to its high efficacy, skin clearance, and treatment satisfaction early in the treatment decision-making process,” the authors wrote, using the trial's abbreviation for risankizumab.

Safety, Sponsorship, and What Is Missing

Treatment-emergent adverse events were reported in 33.6% of the risankizumab group and 42.9% of the deucravacitinib group, with events considered drug-related in 6.1% and 15.3%. The single serious adverse event was a joint injury on risankizumab, deemed unrelated. One patient discontinued risankizumab for episcleritis judged unrelated, compared with 4 discontinuing deucravacitinib. Hypersensitivity reactions ran 7 events in the deucravacitinib arm against 1 in the risankizumab arm, though the 1:2 randomization means those counts come from 262 patients versus 131. Two cases of herpes zoster and 1 nonmelanoma skin cancer were reported, all on deucravacitinib.

The open-label design is the central limitation, mitigated but not erased by blinded efficacy assessment, and the authors acknowledge the enrolled population was not ethnically representative of psoriasis prevalence. Sponsorship deserves equal weight: AbbVie funded the trial, and 7 coauthors are AbbVie employees. A comparison its own sponsor designed and ran is not disqualifying, but it is reason to want the week 52 data and independent replication.

The assumption these data complicate is a common one: that an oral agent belongs first in moderate disease and the biologic is what follows failure. On these numbers, starting oral costs a substantial share of patients their chance at clear skin over 4 months, which is a different calculation for a dermatologist choosing therapy than for the payer reviewing the prior authorization. What 16 weeks cannot show is whether the gap persists or whether patients who switch after an inadequate oral response catch up.

References

1. Magnolo N, Soung J, Frew J, et al. Risankizumab versus deucravacitinib in adults with moderate plaque psoriasis: 16-week results from the phase 4 IMMpactful trial. Dermatol Ther (Heidelb). 2026;16(7):3415-3429. doi:10.1007/s13555-026-01779-x

2. Armstrong AW, Gooderham M, Warren RB, et al. Deucravacitinib versus placebo and apremilast in moderate to severe plaque psoriasis: efficacy and safety results from the 52-week, randomized, double-blinded, placebo-controlled phase 3 POETYK PSO-1 trial. J Am Acad Dermatol. 2023;88(1):29-39. doi:10.1016/j.jaad.2022.07.002