Bruce Strober, MD, PhD, FAAD

Patient-Level Treatment Drivers — Route of Administration, Psoriatic Arthritis, and Comorbidity Considerations 

Strober examines how patient preference for oral versus injectable therapy and the presence and pattern of psoriatic arthritis.

Effective psoriasis management increasingly depends on a treatment selection framework that extends beyond skin severity scores to encompass the full clinical and contextual profile of the individual patient. Route of administration is among the most practically influential of these factors. Many patients express an instinctive preference for oral medications, but that preference is rarely absolute and often shifts when the clinical conversation addresses the full picture of treatment burden — including how often injections actually occur at maintenance and how that compares with the commitment of daily oral dosing. For patients who prioritize the fewest possible interactions with a therapy once disease is controlled, the every-12-weeks maintenance schedule of an IL-23 biologic may ultimately be more acceptable than a once-daily oral pill. The clinician's role is to surface these preferences explicitly rather than assume them, and to provide the comparative context patients need to make an informed choice.

Psoriatic arthritis (PsA) — its presence, severity, and anatomical pattern — is among the most consequential determinants of mechanism selection in patients with psoriatic disease. IL-17 inhibitors carry the most robust data across the full spectrum of PsA domains, including peripheral joint disease, distal interphalangeal involvement, dactylitis, enthesitis, and axial disease, and have demonstrated inhibition of radiographic progression across these domains. For patients with prominent axial psoriatic arthritis in particular, IL-17 blockade remains the preferred mechanism, supported by an evidence base that IL-23 inhibitors have not yet matched for this specific manifestation. That said, guselkumab has recently demonstrated radiographic benefit in psoriatic arthritis, and the differentiation between IL-17 and IL-23 agents in this domain continues to evolve. Conversely, IL-17 inhibitors carry meaningful contraindications in patients with inflammatory bowel disease — a comorbidity that is not uncommon in patients with psoriasis — whereas IL-23 inhibitors can be used across a far broader comorbidity range.

In this segment of the video discussion on psoriasis treatment selection, Bruce Strober, MD, PhD, Clinical Professor of Dermatology at Yale University School of Medicine, describes the practical algorithm he applies at the point of prescribing. IL-23 inhibitors occupy a favored default position in his treatment approach for most patients with skin-predominant disease: they offer infrequent maintenance dosing, an essentially unrestricted comorbidity profile outside of active infection, and long-term durability data that compare favorably with other biologic classes. IL-17 inhibitors are reserved primarily for patients with significant psoriatic arthritis — particularly those with axial involvement — where the evidence for superior joint outcomes justifies accepting the more restrictive contraindication profile. Icotrokinra and other oral agents are positioned for patients who prioritize the oral route and can accept a somewhat lower efficacy ceiling than the most potent injectable biologics. This mechanism-first framework, calibrated by comorbidity and arthritis pattern before patient preference is layered on top, reflects the current complexity of psoriasis care and the degree to which therapeutic selection has evolved from a simple stepwise escalation into a nuanced, multidimensional clinical decision.

Videos

Oral therapies offer convenience, but biologics deliver faster, stronger results; experts weigh psoriatic arthritis, dosing schedules, safety profiles, and IL-17 vs IL-23 choices.

To watch the video series component of this episode, click here. 

5:11 Classifying the Severity of Plaque Psoriasis

8:30 Laboratory Tests for Systemic Therapy

13:22 Monitoring Systemic Therapy in Plaque Psoriasis

16:50 New Oral Systemic Therapies for Plaque Psoriasis

28:03 Long-term Safety Data of Deucravacitinib

34:52 Selecting the Right Treatment for the Right Patient


Podcasts

A panel of dermatologists have a comprehensive discussion on exciting developments in the treatment of plaque psoriasis, focusing on treatment approaches, patient monitoring strategies, and recent clinical trial data.

Beyond the Surface: Monitoring your Patients with Moderate to Severe Plaque Psoriasis

Clinical insights on long-term safety data for deucravacitinib and selecting the right treatment for the right patient.

Deucravacitinib Safety Data and Treatment Selection Considerations

0:05 Long-term Safety Data of Deucravacitinib

6:55 Selecting the Right Treatment for the Right Patient


Bruce Strober, MD, PhD, and Linda Stein Gold, MD, provide clinical insights on long-term safety data for deucravacitinib and selecting the right treatment for the right patient.

Dermatologists have a comprehensive discussion on systemic therapies for the treatment of plaque psoriasis.

Systemic Therapies for Plaque Psoriasis

0:05 Monitoring Systemic Therapy in Plaque Psoriasis

3:34 New Oral Systemic Therapies for Plaque Psoriasis

Dermatologists have a comprehensive discussion on systemic therapies for the treatment of plaque psoriasis, covering monitoring practices, and long term efficacy data  for novel oral agent deucravacitinib.

Bruce Strober, MD, PhD, FAAD

Articles