Biologics for Psoriasis: Are Dual Inhibitors More Effective?

Biologics have transformed how moderate to severe psoriasis is treated, offering people with the chronic autoimmune condition a level of skin clearance and long-term control that wasn’t possible with older therapies.

Most biologics approved for psoriasis block a single inflammatory pathway. A newer option, bimekizumab (Bimzelx), takes a different approach, targeting two pathways at once. But does this dual approach translate into significantly better results for people with psoriasis?

“I often explain to patients that psoriasis is driven by an immune response. Biologics work by selectively blocking specific cytokines, such as IL-23 and IL-17, that signal to the skin to cause inflammation and rapid cell turnover,” says Marisa Garshick, MD, a dermatologist in New York and New Jersey, and a clinical assistant professor of dermatology at NewYork-Presbyterian Weill Cornell Medicine.

“IL-17A is considered the more potent inflammatory signal, while IL-17F is present in higher amounts in psoriatic skin,” says Garshick. “By targeting both, medications like bimekizumab may offer greater suppression of inflammation, which may translate to improved clinical outcomes for some patients, compared with blocking IL-17A alone.”

“It’s about achieving a more complete blockage of the inflammatory signals behind psoriasis,” says Lawrence Green, MD, a clinical professor of dermatology at the George Washington University School of Medicine in Washington, DC.

“Psoriasis isn’t driven by just one signal,” Dr. Green says. “So when you block more than one, like IL-17A and IL-17F, you’re casting a wider net on the inflammation.”

As newer biologics raise the bar for psoriasis treatment, researchers are looking at whether targeting more than one inflammatory pathway can push results even further.

“They do consider it superior in efficacy, but you’re splitting hairs at that point, because all these agents are so effective,” says Chris Adigun, MD, a board-certified dermatologist in private practice in Chapel Hill, North Carolina.

It shows how far psoriasis treatment has come. When Dr. Adigun was training, ”we never even hoped for” that level of skin clearance, she says, adding, “Now we’re aiming for completely clear skin.”

One common question with biologic therapy is whether blocking two inflammatory pathways increases risk.

Dual inhibitors may sound promising for people looking for very high levels of skin clearance, but they’re not automatically the best choice for everyone.

Choosing a biologic is a decision that patients make with their dermatologist, taking into account factors like disease severity, prior treatment response, comorbidities, and practical considerations like insurance coverage, Garshick says.

In some cases, the nature of the psoriasis itself can help guide that decision.

For people with psoriasis that is more inflammatory, “it’s more red, more active, more revved up — that’s where I’m more likely to think about something like bimekizumab,” Green says.

It’s not necessarily about defaulting to the newest drug, especially given how effective biologics are overall. “I don’t need to use something that is shiny and new,” Adigun says. “As we get more options, it becomes less about which drug is better overall and more about which one is the right fit for that patient.”

• Biologic therapies treat moderate to severe psoriasis by blocking specific immune signals, such as IL-17 and IL-23, that cause skin inflammation and rapid cell turnover.
• The dual inhibitor bimekizumab targets two inflammatory pathways (IL-17A and IL-17F) and may offer higher rates of complete skin clearance and faster results than biologics that target a single signal.
• While dual inhibitors are generally well tolerated, they are associated with a higher risk of oral candidiasis, or thrush.
• Choosing the right biologic depends on individual factors, including disease severity, prior treatment response, and insurance coverage.