Q&A: IL-23, Oral Therapies, and Inflammatory Disease Management, With April W. Armstrong, MD, MPH

At the 2026 American Academy of Dermatology (AAD) Annual Meeting, leading experts highlighted the rapid pace of innovation reshaping the management of chronic inflammatory skin diseases.1,2,3,4

Among them, April W. Armstrong, MD, MPH, of the David Geffen School of Medicine at UCLA, spoke about several insights spanning psoriasis, atopic dermatitis, and emerging therapeutic strategies, drawing from multiple sessions in which she participated. In this discussion, Armstrong underscored both the remarkable progress made with the therapeutic landscape, emphasizing the rising importance of mechanism-driven treatment selection, long-term safety data, and individualized patient care.

The following Q&A interview summarizes her responses to inquiries during her HCPLive interview at AAD:

HCPLive: The IL-23 pathway has become a central target in psoriasis over the past few years. How would you characterize what makes IL-23 inhibition mechanistically different, and why has it emerged as a therapeutic target?

Armstrong: There are a few things to consider about IL-23 inhibition. We know that IL-23 inhibition is really central in terms of being this master regulator for diseases such as plaque psoriasis. We actually also know it's really important for conditions such as Crohn's disease or ulcerative colitis, oftentimes comorbidities that are important to our dermatology patients who may have inflammatory skin diseases and have an increased risk of those other conditions. Now, when we're thinking about IL-23, why it's important is that it's very key in terms of making sure that in the process of naive T-cell differentiation, these T cells are differentiated into certain types of cells, such as Th17 cells and so forth.

Because of that, it has a tremendous influence in terms of the pathological states, with regard to potentially directing some of the inappropriately elevated levels of differentiation into Th17 cells that can be pathologic in states such as psoriasis. Now, when we have therapies that target the IL-23 pathway, for example, it can be very specifically targeting that of of diseases that are affected by this, namely psoriasis in this case. Also, what we see is that for therapies that are particularly targeting IL-23, oftentimes, there are very high rates of complete and near-complete skin response with some of the biologics that we've had for a long period of time. One of the distinct advantages of IL-23 modulation or inhibition in psoriasis is that it can get that durable response with extended dosing intervals.

Typically, we're thinking about dosing intervals of every 2 months or every 3 months with our injectable biologics. Now, we do have another class, which is IL-17 inhibitors in psoriasis, that are also extremely highly effective. With the newer IL-17 inhibitors, the dosing intervals are getting closer to those of the IL-23 inhibitors. Getting back to IL-23 inhibition, what we see is that a quite distinctive advantage is the favorable long-term safety profile. What we are seeing is that with patients who have been on IL-23 inhibitors for a while, for example, we have now over 6 or 7 years of long-term extension data. What we see is that it continues to be very safe in our patients who've been taking it for a long period of time, and we don't see signals with regard to serious infections or cancer in those patients who have taken it for a very long time.

HCPLive: We know your session also touches on unmet needs across patient populations. Which patient profiles or clinical scenarios still represent the biggest gaps in the management of psoriasis?

Armstrong: We have come a long way in terms of managing our patients who have psoriasis and psoriatic arthritis, and caring for them has really been a pleasure as a dermatologist, along with our rheumatology colleagues, for the past two decades now. That being said, we also still have a number of areas where we have unmet needs. Number one is thinking about patients who may have limited body surface area involvement, but high-impact site involvement, for example, the treatment of patients with palmoplanter diseases. That's still one area that we are trying to figure out how to better manage that particular disease phenotype. We know that patients with palmoplantar psoriasis have one of the most difficult-to-treat phenotypes, and that is something that we're consistently trying to work on. This includes not only the hyperkeratotic type of palmoplantar psoriasis, but also palmoplantar pustulosis.

Another area is thinking about managing comorbidities in our patients with psoriasis. Namely, looking at obesity a little bit closer. We know that many patients with psoriasis, epidemiologically, there are higher rates of obesity in patients with psoriasis, and newer and newer data show that managing their obesity and getting patients to decrease their weight when they are in the obese category can not only improve their cardiovascular health. That intervention may actually have an independent effect, a positive effect, in terms of reducing their psoriasis or psoriatic arthritis disease activity. This is really interesting data. It's newer data, and something that we as a field are continuing to try to understand.

Then, finally, we may have patients who have severe psoriasis or psoriatic arthritis and who also have various complex comorbidities, and we’re thinking about how to care for those patients and ensure that the therapies that we have for them can potentially address these other comorbidities. But also, even if we have a therapy that's specifically for psoriasis and psoriatic arthritis, in the context of the other complex comorbidities, how can we make sure that these patients are safely managed by our pharmacological or other interventions?

HCPLive: Speaking of interventions, there's a growing number of IL-23 inhibitors now available. How are you thinking about selection and differentiation within your own practice?

Armstrong: We have a number of different IL-23 inhibitors that are available. We have the biologics…and we have a newly-approved IL-23 receptor inhibitor. That's an oral peptide, and that's icotrokinra. So, now we have oral therapies for targeting the IL-23 pathway in patients with plaque psoriasis, as well as biologics. Having all these different options, I think, is really great for our patients, because even within the IL-23 class, we have known from the real-world studies that sometimes failing one IL-23 therapy doesn't necessarily mean that they will fail another IL-23 therapy.

A few things when we're considering these different medications: For example, for patients who have moderate to severe plaque psoriasis, when our dermatologists and dermatology and NPs and PAs are thinking oral therapies could benefit that patient population in terms of targeting the il 23 pathway, we can now, we now have FDA-approved therapy for that, and can consider icotrkinra. When we are looking at icotrokinra, the efficacy rates are at the level of biologics. So that's very exciting and really great news for our patients who especially those who have been wanting an oral therapy for a long time.

When we're looking at our patients who may benefit more potentially in terms of biologic therapies, we have tildrakizumab, which I think is really wonderful for patients who have, for example, Medicare coverage. This is because this tildrakizumab is the only medication within the IL-23 class that's covered under Medicare Part B benefits. So for our patients who are our Medicare age, who may not have good supplemental coverage, for example, that's definitely a good choice. Then we also have, for example, guselkumab and risankizumab, which I think as a field we have known for a very long time to have high efficacy in treating our patients with plaque psoriasis. Also, [they have] very good safety data as well. I think those continue to be excellent choices for patients.

HCPLive: To dermatologists who are in the audience, who may be looking to translate some of these tips into their everyday practice, what would you say are the most immediately actionable takeaways?

Armstrong: I will say when we're thinking about our various options that we have for patients with plaque psoriasis. Now, I think number one, evaluating whether they have psoriatic arthritis is important because there is some differentiation among the various therapies with regard to PsA. That gap, I think, between IL-17s and IL-23s is closing. Newer data also show, for example, that guselkumab can decrease the radiographic progression of patients with psoriatic arthritis. So that's encouraging for our patient, for our patients. The other aspect is, when we're thinking about patients, it's very important to also understand what comorbidities they may have, and some of our therapies have multiple indications.

If they have a certain set of comorbidities where they can use essentially one medication to treat not only psoriasis and psoriatic arthritis, but also, for example, inflammatory bowel disease. Then think about, really thinking about the IL-23 class would be, would be most appropriate for those patients. Also, when we look at our biologics, for example, there are differences, although I would say the differences are pretty small these days, as we're very fortunate to have highly efficacious medications. But there are small differences among the biologics. For example, our newer biologic bimekizumab, which is an IL-17 inhibitor, has very robust, high response rates that we've seen in clinical trials, as well as in the long-term extension studies. That's also something to be aware of.

Finally, as I talked about earlier, we now have oral options. Our IL-23 receptor inhibitor, icotrokinra, has biologic-level efficacy at the level we're seeing. I think the expectation for our oral therapies has increased even more. Also, with two emerging…TYK2 inhibitors coming up through the pipeline, I think we will have better therapies in the future for our patients who desire oral therapies for the management of moderate to severe plaque psoriasis.

HCPLive: Concerning your portion of the ‘What's New in Dermatology’ session you presented on atopic dermatitis, what were some of the treatments that you chose to highlight?

Armstrong: When we are looking at what's new in atopic dermatitis, I feel that the field is ‘drinking from a fire hydrant.’ We have continual innovations in that area, and also at a speed that we really haven't seen before in dermatology. Some of the things that I highlighted in my session included long-term data for the FDA-approved therapies, both in the biologic realm as well as oral JAK inhibitors. Specifically, when we're thinking about safety data, one of the key reassuring messages we've seen with regards to the long term safety for the oral JAK inhibitors is that in the atopic dermatitis population, for example, the rates of serious infections or the rates of MACE events…seem to be quite similar to the background [atopic dermatitis] patients who have moderate to severe disease severity. So that's very important.

Now that being said, it's still very important to make sure that your patients start an oral JAK inhibitor, to make sure that they get their vaccination, especially their Zoster vaccination, because the use of oral JAK inhibitors can be associated with higher rates of zoster. So I want to make sure that all my patients get their Zoster vaccination before or as the second shot, as they started their oral JAK inhibitors. The other aspect that I highlighted in my study is really thinking about emerging therapies and new MOAs for patients with atopic dermatitis. I will say when we're looking at emerging therapies, there are some that are still relying on the existing, proven pathways. But there are also explorations for neural pathways.

For example, now we have more data on the OX40-ligand pathway, and we have longer-term data with regard to that particular pathway. In addition to that, we also see newer innovations in inhibitors that target il four receptor alpha, which we know is a known mechanism, but looking newer innovations, looking at, can we target that even more specifically, potentially leading to greater, greater efficacy, we're also seeing oral therapies that are developed for atopic dermatitis, and not necessarily inhibiting jak Janus kinase molecules, but inhibiting stat six, for example. That's notable as well.

Finally, there are a number of different innovations that are looking at bi-specific or tri-specific molecules that really take advantage of different targets in atopic dermatitis and try to inhibit either two or sometimes even three targets in order to help address the heterogeneity in the patient presentations. And so hopefully, with one therapy, you're able to reach the greatest number of patients possible and have it be effective in the largest number of patients possible. So those are some of the things that I highlighted in my talk at the AAD.

HCPLive: You also discussed oral therapies during AAD. To which oral medications did you refer in this session?

Armstrong: In this particular session, I refer to both the FDA-approved advanced oral therapies that we've been using for a while, things such as deucravacitinib, as well as apremilast, and our newly FDA-approved oral therapy, icotrokinra. I also highlighted two therapies that are TYK2 inhibitors that are emerging, and that just had their phase three readout at the AAD meeting. So, that's all of this, I think, is very exciting, and really shows how oral therapies are the next frontier in terms of development for patients with moderate to severe plaque psoriasis. A few things regarding deucravacitinib that I highlighted are that deucravacitinib is now FDA approved, for example, for the treatment of psoriatic arthritis. That's a very exciting mile marker, I think, for deucravacitinib. We've been using it for plaque psoriasis, and we've also known about the phase three data for a while, so now seeing it being available for patients with PsA, I think that's very exciting.

With regards to icotrokinra, just newly FDA-approved, really thinking about once a day oral therapy that have the level of efficacy that are essentially that's rivaling our biologics and and then thinking about the potential for our patients in the real world now, then that, now that we have a oral therapy that that have a really good safety profile and also high efficacy that we can recommend to our patients. And then finally, when we're looking at newer TYK2 inhibitors and their development, we have zasitnib and mbudocitinib, both of them targeting the tick two inhibitor, but in ways that are even more specific and therefore more potent as well, in terms of their MoA. And so I think what you're seeing is that the really the second generation of TYK2 inhibitors in plaque psoriasis, and their performance is one such that we're seeing higher and higher levels of performance with the second generation of TYK2 inhibitors.

HCPLive: Are there any other notable takeaways that you hope clinicians walk away with from this session?

Armstrong: I think that in addition to the oral therapy session that I covered, the psoriasis symposium, also covered a number of other areas, and I think they will hopefully have learned a lot with regards to some advances in the biologic era and and then also thinking about comorbidities, not just in terms of obesity comorbidities, which We've hasn't gained a lot of press lately, but also thinking about dermatologists role in terms of what that might be, in terms of managing these various comorbidities alongside of our primary care colleagues or other specialties. So there was a debate on whether dermatologists should take on some of the roles, or should we leave that to our primary care or other specialty colleagues?

We're also looking at psoriatic arthritis and understanding how early treatment of not just psoriasis but also psoriatic arthritis can potentially alter the trajectory of both of those conditions, and therefore, the selection of therapy initially is very important in our patient population. And then finally, let's not forget about our pediatric and adolescent patient population. Thankfully, most of our data now that we're seeing in that patient population is that our existing therapies that is approved for adults tend to also work very well in the pediatric patient population, and sometimes even better than what we see in adult population, which speaks to number one, potentially treating psoriasis earlier in that patient population can change the severity of their disease, the natural history of their disease. Also, we know that patients, when they are treated earlier in their disease course, tend to respond better than if they've had the condition for many years and haven't gotten it treated.

The quotes in this Q&A summary were edited for clarity.

Armstrong served as a consultant for and received honoraria from AbbVie, Almirall, Arcutis, ASLAN, Beiersdorf, Boehringer Ingelheim, Bristol Myers Squibb, Dermavant, Dermira, EPI, Incyte, Janssen, LEO Pharma, Eli Lilly, Nimbus, Novartis, Ortho Dermatologics, Pfizer, Regeneron, Sanofi, Sun, and UCB and has participated in advisory boards for Boehringer Ingelheim and Parexel.

References

1. Armstrong A, et al. S065 What's New in Dermatology. Session presented at: 2026 American Academy of Dermatology Annual Meeting; March 27–31, 2026; Denver, CO.

2. Armstrong A, et al. S043 Psoriasis. Session presented at: 2026 American Academy of Dermatology Annual Meeting; March 27–31, 2026; Denver, CO.

3. Armstrong A, Strober B, Hawkes J, et al. INC01 IL-23 Innovation: New Data Addressing Plaque Psoriasis. Session presented at: 2026 American Academy of Dermatology Annual Meeting; March 27–31, 2026; Denver, CO.