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With so many effective biologics on the market for psoriasis and related conditions, it can be challenging to identify the best ones. A new clinical evidence synopsis covering 18 different psoriasis therapies and based on extensive data from Cochrane Reviews helps clinicians sort out the best options for their patients.

According to the synopsis, which appeared in , the most effective drugs for psoriasis were infliximab, bimekizumab, ixekizumab, and risankizumab. No statistically significant differences in serious adverse events were identified in any of the drugs compared with placebo.

Andrew Blauvelt, MD, MBA, dermatologist and scientific consultant with Blauvelt Consulting, LLC, served as a co-author of the analysis. His exchange with the Reading Room has been edited for length and clarity.

What was the context for setting out on this analysis and what was the key question or knowledge gap it was designed to address?

Blauvelt: Cochrane Reviews are major systematic reviews that are done periodically on a given topic. They are usually massive -- in this case hundreds of pages long. I was asked to summarize the Cochrane Review, basically to make it more digestible. So it's a review of a review. The goal was to summarize and provide highlights.

Would you summarize those highlights in terms of effectiveness, adverse events, or other factors?

Blauvelt: There are 12 different biologics for psoriasis -- and that's a lot. There are a lot of data. And there are a number of different oral meds for psoriasis ... upwards of about six now, depending on if you go to Europe or the U.S. Currently, 18 medicines are available for treatment of moderate-to-severe psoriasis.

We looked at different classes as part of our review. Infliximab was considered the best TNF blocker. Bimekizumab (the newest biologic) and ixekizumab were considered the best IL-17 blockers. Risankizumab was considered the best IL-23 blocker.

Dermatologists usually pick a class of drug for their patient based on not just efficacy, but whether the treatment works in, for example, psoriatic arthritis. It's not just as simple as using the best drugs. As a clinician I want to also make sure I provide the best drug for my patient.

That's why I'm emphasizing that those are the four drugs that emerged as best in class. If you're going to use a certain class of drug because of a comorbidity, like psoriatic arthritis, one would choose an IL-17 blocker. And of course, this doesn't mean that all the other drugs are bad, because the other drugs are good too. But the title of the article is "The Best Medications Emerge," so we highlighted the top performing drugs in each class.

Did anything strike you as a surprise at all as you conducted the review?

Blauvelt: There were a couple of surprises. One was that the Cochrane authors thought that the drugs were all equally safe. And I think, in general, we do not think of them as equally safe.

For example, we consider the TNF blockers -- the older biologics -- to be generally less safe than the newer IL-17 and IL-23 blockers. But that was not the conclusion of the Cochrane Review.

There also was no consideration for comorbidities. You choose a drug not just by skin efficacy, but also by what's happening with joint efficacy, depending on each individual patient.

Further, the authors only looked at data out to one year. But we know that certain drugs show a lack of clinical effectiveness beyond 52 weeks or over years of use. So that was another drawback. For example, guselkumab did not come out as one of the top four drugs, but it has been shown to be an outstanding drug in terms of durability in real-world settings. Durability is a surrogate marker for effectiveness in real-world settings. So the drug that has been shown to have the best durability beyond one year did not come out on top in this analysis.

What are your key take-away messages for dermatologists?

Blauvelt: One of the bottom-line messages is that we have an embarrassment of riches in terms of highly effective and highly safe treatments for psoriasis. One of the things that I emphasize strongly when I'm teaching dermatologists is that there are still dermatologists practicing in the community who do not use biologics. And I think that's a travesty. How much more evidence do we need of safety and efficacy for people to finally start using biologics in their practice?

One of my theories is that there was an imprinting 20 years ago when TNF blockers came out and there were safety warnings and issues. I think some clinicians decided they were not going to use these drugs at that point and have not been paying attention to all the advancements and improvements with the IL-23 and IL-17 blockers, which have reached new heights in terms of efficacy and safety.

So I think some messages for the clinician would be that you shouldn't have any fear of using biologics for patients with psoriasis. The benefits far outweigh the risks.

Also, you should probably pick one top drug in each class if you're worried about learning about all of them. My main message is: you don't have to learn all the drugs; you don't have to learn all the data. You can look to reviews like this and then just select the best-in-class for your use in your office, so no one gets overwhelmed. Rather than get paralyzed and use nothing, practitioners can look to reviews like this to select the best-in-class drugs that have already been identified for them.