ABCs in Dermatology: Updates in Psoriasis Management for 2026

Treating psoriasis to clear or almost clear skin, rather than partial improvement, is emerging as the standard clinicians should hold themselves to across every affected body site, including the scalp, nails, and genitals. Special sites carry a disproportionate quality-of-life burden relative to their body surface area (BSA) and are increasingly recognized by clinical guidelines as sufficient grounds for systemic therapy on their own.

In an episode of ABCs in Dermatology recorded at Revolutionizing Atopic Dermatitis 2026, Lindsay Ackerman, MD, and Christopher Bunick, MD, PhD, discussed data supporting transformational care in psoriasis, with a focus on risankizumab and the underappreciated burden of special-site disease.

International Psoriasis Council guidelines now define systemic eligibility using 3 criteria:

• 10% or greater BSA involvement
• Disease in hard-to-treat areas such as the scalp, nails, palms, soles, or genitals
• Failure of 2 topical therapies used for at least 4 weeks each

Special-site involvement matters beyond symptom burden: scalp disease confers a fourfold higher risk of psoriatic arthritis, and nail disease a 3-fold higher risk, against a baseline lifetime psoriatic arthritis risk of roughly 30% to 35% across the psoriasis population.

In the phase 3 UltIMMa-1 and UltIMMa-2 trials, risankizumab, an IL-23 p19 inhibitor dosed every 12 weeks, achieved PASI 90 in about 75% of patients by week 16. In the head-to-head IMMerge trial, risankizumab sustained superiority over secukinumab through week 52. Long-term LIMMitless extension data showed durability, with response curves for modified non-responder imputation and as-observed analyses nearly superimposed, and roughly 54% of patients reaching PASI 100 by week 304. In the phase 3b IMMprint trial, risankizumab also demonstrated efficacy in palmoplantar psoriasis, an area with thicker epidermis that is traditionally difficult to clear.

The speakers noted structural differences among IL-23 p19 inhibitors, including epitope binding surface area and dissociation rate, may help explain efficacy differences observed across the class. Risankizumab has also shown a 10% to 20% efficacy advantage over the oral IL-23 receptor blocker icotrolimod in indirect comparisons, alongside evidence that IL-23 inhibition may delay psoriatic arthritis onset more effectively than other mechanisms.

Collectively, the data support a shift in benchmark thinking, from PASI 75 toward PASI 90 and 100, and reinforce special-site and nail involvement as legitimate, guideline-recognized triggers for systemic therapy rather than exceptions to standard BSA-based criteria.

References

1. Gordon KB, Strober B, Lebwohl M, et al. Efficacy and safety of risankizumab in moderate-to-severe plaque psoriasis (UltIMMa-1 and UltIMMa-2): results from two double-blind, randomised, placebo-controlled and ustekinumab-controlled phase 3 trials. Lancet. 2018;392(10148):650-661. doi:10.1016/S0140-6736(18)31713-6

2. Warren RB, Blauvelt A, Poulin Y, et al. Efficacy and safety of risankizumab vs. secukinumab in patients with moderate-to-severe plaque psoriasis (IMMerge): results from a phase III, randomized, open-label, efficacy-assessor-blinded clinical trial. Br J Dermatol. 2021;184(1):50-59. doi:10.1111/bjd.19341

3. Papp KA, et al. Long-Term Safety and Efficacy of Risankizumab to Treat Moderate-to-Severe Plaque Psoriasis: Final LIMMitless Phase 3, Open-Label Extension Trial Results. Am J Clin Dermatol. 2025. doi:10.1007/s40257-025-00964-6

4. Lebwohl M, Bukhalo M, Bissonnette R, et al. A randomized phase 3b study evaluating the safety and efficacy of risankizumab in adult patients with moderate-to-severe plaque psoriasis with non-pustular palmoplantar involvement. J Am Acad Dermatol. 2024. doi:10.1016/j.jaad.2024.07.1521