First-Line Biologic Selection in High-Risk Psoriasis: The Role of IL-23 Inhibition

Saakshi Khattri, MD, describes how risk factors for psoriatic arthritis influence her decision to use IL-23 inhibitors such as risankizumab as first-line systemic therapy in psoriasis.

In this segment, Saakshi Khattri, MD, addresses how the emerging data on PsA risk reduction with risankizumab informs first-line biologic selection in patients with psoriasis who have recognized risk factors for PsA. She highlights that patients with nail disease, scalp involvement, intertriginous psoriasis, a family history of PsA, obesity, and smoking history may carry a higher likelihood of progression from skin-only disease to joint involvement. Even in the setting of limited body surface area (BSA) involvement, she considers these risk factors when deciding whether to initiate systemic therapy.

Khattri notes that real-world data suggesting a lower incidence of PsA with IL-23 inhibition have meaningfully influenced her clinical practice. Although the evidence is retrospective and subject to inherent limitations, she reports an increasing tendency to use IL-23 inhibitors, including risankizumab, as first-line biologic therapy for appropriate psoriasis patients, particularly those deemed at higher risk for PsA. This shift reflects both the biologic rationale for targeting IL-23 and the signal that this pathway may be associated with reduced transition from skin disease to joint disease.

As a rheumatologist, Khattri also underscores the importance of ongoing vigilance for early joint symptoms, regardless of the systemic agent chosen. She routinely performs joint examinations, evaluates for enthesitis and dactylitis, and asks about morning stiffness at each visit.

For patients with psoriasis but no established PsA, she views IL-23 inhibition as a compelling option, while emphasizing that careful musculoskeletal assessment remains essential to detect PsA early should it develop.