Treat to Target in Psoriasis: A Real-World Experience With Biologics and Adjunctive Topical Therapy

The new treat-to-target goal for patients with plaque psoriasis – ≤ 1% of BSA involvement at 3 months after treatment initiation or 6 months of a maintenance regimen – has become a tangible and practical goal for physicians and patients to aim for improved disease control.¹ Treat-to-clear is not a new concept – phototherapy can achieve complete response and clearance tends to prolong remission. On the other hand, treatment with methotrexate requires a dosage-balancing strategy to maximize efficacy while minimizing toxicity.² The advent of anti-IL-17 therapy in the treatment of psoriasis delivered the first PASI 100 end point, beginning an era of “treat to clear” with biologic monotherapy. Forty-two percent of subjects treated with a 12-weeks regimen of ixekizumab, a monoclonal antibody that blocks IL-17, achieved PASI 100.³Nonetheless, not all patients achieve treat-to-target goals with the current therapeutic selection; in the case of ixekizumab, 58% of patients still had persistent disease activity. As greater disease activity is associated with worse quality of life, new strategies to attain these goals are needed.⁴ In patients who have had a good response with biologics without adverse events or for patients who have acceptable response to biologic therapy but have residual disease activity, combination therapy with adjunctive topical agents can be a preferred option for enhancing their response over switching to a different biologic agent.^5-7 The topical agent added should be cosmetically acceptable, be dosed preferably once daily to enhance adherence, and have a demonstrated good efficacy and safety profile.In the current issue of Journal of Drugs in Dermatology, my colleagues and I show that treat-to-target was attainable in a real-world setting in a majority of patients as early as week 4, when they were treated with the combination of adjunctive use of topical calcipotriene 0.005%/betamethasone dipropionate 0.064% (Cal/BD) foam and biologics. Notably, the patients enrolled in this study had significant disease activity despite being on a stable regimen (≥ 24 weeks) with a variety of biologics, including ustekinumab, adalimumab, secukinumab, etanercept, and ixekizumab. Seventy-six percent of patients in the prospective, open label study improved to BSA involvement ≤1% and PGA score ≤1. Further, 28% of patients achieved total clearance of plaque psoriasis (no BSA involvement and PGA score of 0). Treatment success was maintained even with switching to weekend only (twice weekly) application of the Cal/BD foam for up to 16 weeks. Overall, the study provides a practical solution for patients to add an effective and safe topical therapy to their stable biologic regimen to achieve treat-to-target goal without the need to switch or escalate biologic therapy.Importantly, it is encouraging to see that adjunctive topical therapy to biologic treatment can be used as a strategy to bring treat-to-target within closer reach than ever before for physicians and patients alike. This is indeed a new era that promises better quality of care for individuals living with psoriasis.References