Biologic agents relieve chronic skin conditions where other treatments fail

Key Points

A small number of patients are treated with biologics, and treatment tends to be personalized, Dr. Feldman says. As such, he says he suggests dermatologists familiarize themselves with all of these drugs, educate their patients about the most appropriate options available to them, and to involve patients with drug selection.

Biologics, a class of drugs that produced through biological processes involving recombinant DNA technology, may be used to treat certain chronic dermatologic conditions. They include adalimumab (Humira, Abbott), etanercept (Enbrel, Amgen/Pfizer), infliximab (Remicade, Janssen Biotech) and ustekinumab (Stelara, Janssen Biotech). Often, they are used to treat cases of moderate-to-severe psoriasis and psoriatic arthritis.

Examining options

Dr. Feldman says he has prescribed tumor necrosis factor-alpha (TNF-alpha) inhibitors, such as etanercept, adalimumab and sometimes infliximab, as well as the CD2 antagonist alefacept (Amevive, Astellas) and human interleukin-12/23 monoclonal antibody ustekinumab. Alefacept recently was taken off the market, however.

"Humira requires fewer injections," he says. "It may be a little more potent for most people on average. Because it's more potent, potentially it could have more safety risk, though overall, the biologics appear to have an excellent risk/benefit profile."

Patient selection

Dr. Feldman says he uses biologics for patients in whom other treatments have failed. "For psoriasis, which is the main use, if somebody just has spots on their elbows and knees, it's not a recommended therapy at all," he says. "If they've got severe psoriasis, then trying to get the psoriasis under control with phototherapy is generally considered the first line of treatment."

Phototherapy is combined with the use of topical medications. "There, you're not affecting the internal immune system; you're not creating risks of opportunistic infection," Dr. Feldman says.

If this treatment plan is ineffective, methotrexate or biologics would be the second line of therapy, he notes.

Some argue about the feasibility and accessibility of phototherapy to some patients, however.

"If you require patients to come to an office for the light treatment, that can be very difficult for a lot of people who live a long way away or are busy with their jobs," Dr. Feldman says. "But if you're willing to prescribe a home light unit, it makes phototherapy feasible for the great majority of the people with severe psoriasis, assuming the insurance company will pay for it."