Biologic Use in Psoriasis Raises Risk of Superficial Fungal Infection Among Patients

Treatment of patients living with psoriasis with biologics, especially interleukin (IL)-17 inhibitors, notably raises their risk of superficial fungal infections, according to recent findings.1

These data resulted from an analysis led by such investigators as Heli Liu, from the Department of Dermatology and Venereology at the Third Hospital of Shanxi Medical University in China. Liu and colleagues noted the importance of biologic agents as an option for moderate-to-severe psoriasis, though they added that risk of superficial fungal infections, such as Candida and dermatophytes infections, had still been unclear prior to their research.2

“Although some clinical studies have investigated the risk of superficial fungal infections associated with various biologic agents, the available evidence remains limited and fragmented,” Liu and coauthors wrote.1 “Therefore, this study aims to systematically synthesise and quantitatively assess the existing data through a meta-analysis, providing more robust evidence to support clinical decision-making.”

The investigative team identified all of the necessary randomized controlled trials (RCTs) for their analysis published up to December 2024 systematically, specifically implementing comprehensive searches across the Embase, PubMed, the Cochrane Library, and Web of Science (WOS) databases. They implemented terms in English for their searches such as “biologics,” "psoriasis," “anti-IL-17,” and “anti-TNF."

They also used terms related to fungal infections such as “onychomycosis,” “Candida,” “dermatophyte infections,” and “tinea pedis." Additionally, the database searches included terms for therapies such as "secukinumab," “etanercept,” “ixekizumab,” “bimekizumab,” “brodalumab," “guselkumab,” “ustekinumab,” "adalimumab," and “tildrakizumab.”

For studies to be eligible for inclusion in Liu et al's research, they needed to meet a specific set of criteria. Specifically, participant groups were required to have comparable baseline characteristics, study designs had to be RCT, patients in studies were required to have had a confirmed diagnosis of moderate-to-severe plaque psoriasis, studies were required to report data on the incidence of superficial fungal infections linked with biologic use, and the control arm needed to include either a conventional systemic treatment, another biologic, or placebo.

Screening of the studies included in Liu and coauthors' analysis was done via 2 independent reviewers who would assess both titles and abstracts for relevance. This was then followed by a full-text review to apply the necessary criteria for inclusion and exclusion. They evaluated quality of RCTs independently through the use of the Cochrane Handbook for Systematic Reviews of Interventions (version 5.1.0). The investigators conducted meta-analyses via RevMan 5.4 and STATA 16.0 software.

There were 29 of the initial pool of 644 records deemed eligibile for inclusion in the meta-analysis. The findings resulting from the study showed that IL-17 inhibitors were substantially linked with an elevated Candida infection risk compared to placebo (odds ratio [OR], 2.39; 95% CI, 1.84–3.11; P < .00001).

This was compared to a lack of statistically significant differences in Candida risk for IL-12/23 (IL-12/23) inhibitors (OR, 1.11; 95% CI, 0.27–4.63; P = .88) or tumor necrosis factor-alpha (TNF-α) inhibitors (OR, 1.75; 95% CI, 0.53–5.82; P = .36) when compared to placebo. In comparisons to biologic classes directly, IL-17 inhibitors showed a greater risk of Candida infections versus TNF-α (OR, 2.23; 95% CI, 1.08–4.57; P = .03) and IL-12/23 inhibitors (OR, 4.21; 95% CI, 2.71–6.55; P < .00001).

In their evaluations of dermatophyte infection risk, Liu and colleagues' meta-analysis showed that the utilization of biologics overall showed a link to a significantly increased risk (OR, 1.89; 95% CI, 1.19–3.01; P = .007). They further highlighted the far greater risk IL-17 inhibitors posed in terms of dermatophyte infections versus IL-12/23 inhibitors (OR, 2.70; 95% CI, 1.29–5.63; P = .008). Collectively, the investigators' analysis pointed to a significantly increased overall risk with biologic therapies in terms of superficial fungal infections compared to placebo (OR, 2.10; 95% CI, 1.73–2.55; P < .00001).

“Future research should integrate real-world evidence and long-term follow-up data to comprehensively assess the infection risk profiles associated with biologic therapy in psoriasis and to optimise individualised dosing strategies,” the investigators concluded.1

References

1. H Liu, L Zhou, Z Song, Y Kang, et al. Biologic Therapy and Superficial Fungal Infection Risk in Moderate-to-Severe Psoriasis: A Meta-Analysis. Mycoses 68, no. 6 (2025): e70081, https://doi.org/10.1111/myc.70081.

2. D Rigopoulos, R Baran, S Chiheb, et al. Recommendations for the Definition, Evaluation, and Treatment of Nail Psoriasis in Adult Patients With No or Mild Skin Psoriasis: A Dermatologist and Nail Expert Group Consensus. Journal of the American Academy of Dermatology 81, no. 1 (2019): 228–240.