Risankizumab and Treatment Sequencing in Scalp and Genital Psoriasis, With Eingun James Song, MD

During an on-site interview at the 2025 European Academy of Dermatology and Venereology (EADV) Congress in Paris, Eingun James Song, MD, of Frontier Dermatology, touched on the topic of treatment sequencing, in light of his recent phase 4 data on risankizumab for those with moderate to severe scalp and genital psoriasis.1

Song’s team recently authored the UnlIMMited study, a multicenter, randomized, double-blind, placebo-controlled trial evaluating risankizumab. The team designed the study to address a historically underrepresented patient population in clinical research: patients with limited body surface area (BSA) involvement but with psoriasis affecting high-impact regions of the body such as the scalp and genitals.

“In the risankizumab studies, there were some patients who were on a prior systemic agent before,” Song explained. “So for the genital cohort, over 10% of these patients were on ixekizumab, an IL-17a inhibitor, with actually really good data for the genital scan, and then for the scalp group, we saw over 10% of these patients were either on adalimumab, a TNF alpha inhibitor, or apremilast, an oral PDE4 inhibitor. While we don't necessarily know how those patients responded to those prior therapies, what we can say is that people who've been exposed to those other biologics or DMARDs in the past, even if they didn't necessarily achieve a certain level of response, we are still seeing very high levels of response with risankizumab.”

Song noted that a caveat to his comments is that the numbers in this research are smaller and the data on these prior therapies are not known.

“My feelings on this, just based on my anecdotal experience, are that patients who don't do well with one particular agent, if they have very little response, we generally will switch out of the class,” Song said. “So if a patient was on an IL-17 or a TNF inhibitor before, and they had very little movement in their skin clearance, then we probably would move to an IL-23 inhibitor.”

In his discussion of treatment sequencing, Song highlighted the necessity of balancing risks and benefits.

“Purely from that standpoint, it is really hard to argue against the fact that an IL-23 inhibitor makes a very compelling case to be a first-line agent for patients if they've never been on anything before,” Song said. “Even for patients who've been on a systemic and maybe didn't get the result that they wanted…If there's maybe one thing I want you to take away from this study, it's that even in patients who have lower body surface areas, if they have a higher impact area that affects their quality of life [in a way that is] comparable to patients with much more extensive body surface area. So please don't under-treat these patients with just topicals. If they're not responding, at least consider escalating these patients to a systemic agent.”

Song has been a consultant, speaker or investigator for the following companies: AbbVie, Janssen, Amgen, Lilly, SUN, UCB, Incyte, Novartis, Sanofi & Regeneron, Castle Biosciences, and Pfizer.

References

1. Song J, et al. Safety and Efficacy of Risankizumab in Genital and Scalp Psoriasis in the UnlIMMited Phase 4 Randomized Clinical Trial at Week 16. Presented at the 2025 European Academy of Dermatology and Venereology (EADV) Congress, Sept 17-20, 2025.

2. Song J. Spotlighting New Data on Risankizumab for Scalp and Genital Psoriasis, With Eingun James Song, MD. HCPLive. September 17, 2025. https://www.hcplive.com/view/spotlighting-new-data-risankizumab-scalp-genital-psoriasis-eingun-james-song-md. Accessed September 18, 2025.