Comparative Efficacy of Biologics vs. Conventional Therapies in Psoriasis: A Meta-Analysis of a Decade of Progress From 2015 to 2025

Samar Ahmed Jasim; Ethar Thaer Mustafa; Shaymaa Khalid Abdulqader

doi:10.54133/ajms.v9i2.2483

Authors

Samar Ahmed Jasim Department of Dermatology, Al-Kindy College of Medicine, University of Baghdad, Baghdad, Iraq https://orcid.org/0009-0001-4669-5691
Ethar Thaer Mustafa Department of Dermatology, College of Medicine, Al-Iraqiya University, Baghdad, Iraq https://orcid.org/0009-0004-7317-4121
Shaymaa Khalid Abdulqader Department of Radiology, Al-Kindy College of Medicine, University of Baghdad, Baghdad, Iraq https://orcid.org/0000-0001-7029-0451

DOI:

https://doi.org/10.54133/ajms.v9i2.2483

Keywords:

Biological therapy, Conventional systemic therapy, Meta-analysis, Psoriasis area severity index, Safety profile

Abstract

Background: The treatment of moderate-to-severe psoriasis has advanced significantly with the use of biologic treatments. Objective: To compare the effectiveness, safety, and impact on quality of life of biologic therapies versus conventional systemic therapies for moderate-to-severe psoriasis, using evidence from 2015 to 2025, focusing on the implications for understudied regions such as Iraq and the Middle East. Methods: Data was collected using "Embase," "MEDLINE," "PubMed," and "Cochrane Central Register." The study includes 45 randomized controlled trials. Additionally, 25 key real-world evidence studies were included for qualitative synthesis to provide context on long-term drug survival, quality of life, and regional applicability. Efficacy was assessed using Psoriasis Area Severity Index (PASI) 75, 90, and 100 response rates at both short-term (10-16 weeks) and long-term (44-60 weeks) intervals. Statistical analyses included Bayesian network meta-analysis and hierarchical cluster analysis. Results: Biological therapies, specifically IL-17 and IL-23 inhibitors, outperformed conventional therapy. In real-world research, 59.7% of patients on secukinumab attained PASI 90 at 3 months, compared to 18.8% with traditional systemics (p<0.001). Biologics also demonstrated a faster time to response (3.04 vs. 6.12 days), increased treatment survival rates, and better quality of life. Safety profiles were favorable, with class-specific hazards (e.g., infections, candidiasis) managed by screening. Conclusions: Biological treatments represent an improved therapy approach for moderate-to-severe psoriasis, providing more rapid, effective, and long-term clearance with a manageable safety profile. These findings call for revisiting traditional first-line therapy strategies, particularly in countries like those in the Middle East, where local data is lacking.

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References

Heller MM, Wong JW, Nguyen TV, Lee ES, Bhutani T, Menter A, et al. Quality-of-life instruments: evaluation of the impact of psoriasis on patients. Dermatol Clin. 2012;30(2):281-291, ix. doi: 10.1016/j.det.2011.11.006. DOI: https://doi.org/10.1016/j.det.2011.11.006

Garshick MK, Kimball AB. Psoriasis and the life cycle of persistent life effects. Dermatol Clin. 2015;33(1):25-39. doi: 10.1016/j.det.2014.09.003. DOI: https://doi.org/10.1016/j.det.2014.09.003

Sondermann W, Djeudeu Deudjui DA, Körber A, Slomiany U, Brinker TJ, Erbel R, et al. Psoriasis, cardiovascular risk factors and metabolic disorders: sex-specific findings of a population-based study. J Eur Acad Dermatol Venereol. 2020;34(4):779-786. doi: 10.1111/jdv.16029. DOI: https://doi.org/10.1111/jdv.16029

Zheng Q, Kuai L, Jiang W, Qiang Y, Wei L, Chen S, et al. Clinical feature, lifestyle behavior and non-communicable diseases comorbidities among psoriasis patients in Shanghai: Gender disparity analysis based on a cross-sectional study. Clin Cosmet Investig Dermatol. 2022;15:2751-2762. doi: 10.2147/CCID.S393697. DOI: https://doi.org/10.2147/CCID.S393697

Murer C, Sgier D, Mettler SK, Guillet C, Maul JT, Djamei V, et al. Gender differences in psoriasis: a Swiss online psoriasis survey. Arch Dermatol Res. 2021;313(2):89-94. doi: 10.1007/s00403-020-02066-1. DOI: https://doi.org/10.1007/s00403-020-02066-1

Gonzalez J, Cunningham K, Perlmutter J, Gottlieb A. Systematic review of health-related quality of life in adolescents with psoriasis. Dermatology. 2016;232(5):541-549. doi: 10.1159/000450826. DOI: https://doi.org/10.1159/000450826

Ryan C, Sadlier M, De Vol E, Patel M, Lloyd AA, Day A, et al. Genital psoriasis is associated with significant impairment in quality of life and sexual functioning. J Am Acad Dermatol. 2015;72(6):978-983. doi: 10.1016/j.jaad.2015.02.1127. DOI: https://doi.org/10.1016/j.jaad.2015.02.1127

Arora S, Das P, Arora G. Systematic review and recommendations to combine newer therapies with conventional therapy in psoriatic disease. Front Med (Lausanne). 2021;8:696597. doi: 10.3389/fmed.2021.696597. DOI: https://doi.org/10.3389/fmed.2021.696597

Garber C, Plotnikova N, Au SC, Sorensen EP, Gottlieb A. Biologic and conventional systemic therapies show similar safety and efficacy in elderly and adult patients with moderate to severe psoriasis. J Drugs Dermatol. 2015;14(8):846-852. PMID: 26267729.

Zuber M, Harikrishna, Vidhyashree, Chhabra M, Venkataraman R, Kumar S, et al. Methotrexate related cutaneous adverse drug reactions: a systematic literature review. J Basic Clin Physiol Pharmacol. 2021;33(5):549-565. doi: 10.1515/jbcpp-2021-0165. DOI: https://doi.org/10.1515/jbcpp-2021-0165

Balak DMW. First-line systemic treatment of psoriasis: staying conventional or going biologic? Br J Dermatol. 2017;177(4):897-898. doi: 10.1111/bjd.15885. DOI: https://doi.org/10.1111/bjd.15885

Torres T, Barcelos A, Filipe P, Fonseca JE. A systematic review with network meta-analysis of the available biologic therapies for psoriatic disease domains. Front Med (Lausanne). 2021;7:618163. doi: 10.3389/fmed.2020.618163. DOI: https://doi.org/10.3389/fmed.2020.618163

Karamanakos A, Vergou T, Panopoulos S, Tektonidou MG, Stratigos AJ, Sfikakis PP. Psoriasis as an adverse reaction to biologic agents beyond anti-TNF-α therapy. Eur J Dermatol. 2021;31(3):307-317. doi: 10.1684/ejd.2021.4056. DOI: https://doi.org/10.1684/ejd.2021.4056

Liu T, Li S, Ying S, Tang S, Ding Y, Li Y, et al. The IL-23/IL-17 pathway in inflammatory skin diseases: From bench to bedside. Front Immunol. 2020;11:594735. doi: 10.3389/fimmu.2020.594735. DOI: https://doi.org/10.3389/fimmu.2020.594735

Ali Z, Matthews R, Al-Janabi A, Warren RB. Bimekizumab: a dual IL-17A and IL-17F inhibitor for the treatment of psoriasis and psoriatic arthritis. Expert Rev Clin Immunol. 2021;17(10):1073-1081. doi: 10.1080/1744666X.2021.1967748. DOI: https://doi.org/10.1080/1744666X.2021.1967748

Oliveira DG, Faria R, Torres T. An overview of bimekizumab for the treatment of psoriatic arthritis: The evidence so far. Drug Des Devel Ther. 2021;15:1045-1053. doi: 10.2147/DDDT.S267405. DOI: https://doi.org/10.2147/DDDT.S267405

Fragoulis GE, Siebert S. The role of IL-23 and the use of IL-23 inhibitors in psoriatic arthritis. Musculoskeletal Care. 2022;20 Suppl 1(Suppl 1):S12-S21. doi: 10.1002/msc.1694. DOI: https://doi.org/10.1002/msc.1694

Soni B, Shivgotra R, Trehan K, Chhina A, Saini M, Jain SK, et al. An overview of contemporary and future therapeutic strategies for scalp psoriasis. Curr Drug Targets. 2024;25(5):353-373. doi: 10.2174/0113894501292755240304063020. DOI: https://doi.org/10.2174/0113894501292755240304063020

Stein Gold L, Eyerich K, Merola JF, Torres J, Coates LC, Allegretti JR. Oral peptide therapeutics as an emerging treatment modality in immune-mediated inflammatory diseases: A narrative review. Adv Ther. 2025;42(7):3158-3172. doi: 10.1007/s12325-025-03213-8. DOI: https://doi.org/10.1007/s12325-025-03213-8

Childs BA, Merola JF. Novel therapeutic targets in the management of psoriatic disease. Rheum Dis Clin North Am. 2025;51(3):447-468. doi: 10.1016/j.rdc.2025.05.005. DOI: https://doi.org/10.1016/j.rdc.2025.05.005

Bissonnette R, Luger T, Thaçi D, Toth D, Lacombe A, Xia S, et al. Secukinumab demonstrates high sustained efficacy and a favourable safety profile in patients with moderate-to-severe psoriasis through 5 years of treatment (SCULPTURE Extension Study). J Eur Acad Dermatol Venereol. 2018;32(9):1507-1514. doi: 10.1111/jdv.14878. DOI: https://doi.org/10.1111/jdv.14878

Reich K, Kristensen LE, Smith SD, Rich P, Sapin C, Leage SL, et al. Efficacy and safety of ixekizumab cersus adalimumab in biologic-naïve patients with active psoriatic arthritis and moderate-to-severe psoriasis: 52-week results from the randomized SPIRIT-H2H trial. Dermatol Pract Concept. 2022;12(2):e2022104. doi: 10.5826/dpc.1202a104. DOI: https://doi.org/10.5826/dpc.1202a104

Armstrong AW, Puig L, Joshi A, Skup M, Williams D, Li J, et al. Comparison of biologics and oral treatments for plaque psoriasis: A meta-analysis. JAMA Dermatol. 2020;156(3):258-269. doi: 10.1001/jamadermatol.2019.4029. DOI: https://doi.org/10.1001/jamadermatol.2019.4029

Castro-Ayarza JR, Barbosa-Rengifo M, Franco-Franco M, Amador JR, Cárdenas-Rojas P, Becerra-Arias C, et al. Biological therapy optimization in patients with psoriasis by reducing the dose or increasing the time interval, in a specialized centre in Colombia. Revista Colombiana de Reumatologia. 2023;30:S65–S69. doi: 10.1016/j.rcreu.2023.02.012. DOI: https://doi.org/10.1016/j.rcreu.2023.02.012

Lebwohl M, Strober B, Menter A, Gordon K, Weglowska J, Puig L, et al. Phase 3 studies comparing brodalumab with ustekinumab in psoriasis. N Engl J Med. 2015;373(14):1318-1328. doi: 10.1056/NEJMoa1503824. DOI: https://doi.org/10.1056/NEJMoa1503824

Steinzor P. Icotrokinra results show 75% of adolescents with plaque psoriasis achieved completely clear skin and demonstrate favorable safety profile in a once daily pill. AJMC. 2025. Available at: https://www.ajmc.com/view/icotrokinra-shows-clear-skin-in-75-of-adolescents-with-plaque-psoriasis-in-phase-3-trial

Gordon KB, Strober B, Lebwohl M, Augustin M, Blauvelt A, Poulin Y, 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. DOI: https://doi.org/10.1016/S0140-6736(18)31713-6

Griffiths CE, Reich K, Lebwohl M, van de Kerkhof P, Paul C, Menter A, et al. Comparison of ixekizumab with etanercept or placebo in moderate-to-severe psoriasis (UNCOVER-2 and UNCOVER-3): results from two phase 3 randomised trials. Lancet. 2015;386(9993):541-551. doi: 10.1016/S0140-6736(15)60125-8. DOI: https://doi.org/10.1016/S0140-6736(15)60125-8

Sharif ZSM, Hussein ZHS, Dahed ZAS, Dhahi ZHH. Review study of psoriasis in Iraq. Eur J Med Genet Clin Biol. 2024;1(6):1–9. doi: 10.61796/jmgcb.v1i6.525. DOI: https://doi.org/10.61796/jmgcb.v1i6.525

Blauvelt A, Reich K, Tsai TF, Tyring S, Vanaclocha F, Kingo K, et al. Secukinumab is superior to ustekinumab in clearing skin of subjects with moderate-to-severe plaque psoriasis up to 1 year: Results from the CLEAR study. J Am Acad Dermatol. 2017;76(1):60-69.e9. doi: 10.1016/j.jaad.2016.08.008. DOI: https://doi.org/10.1016/j.jaad.2016.08.008

Addor FAS. Beyond photoaging: additional factors involved in the process of skin aging. Clin Cosmet Investig Dermatol. 2018;11:437-443. doi: 10.2147/CCID.S177448. DOI: https://doi.org/10.2147/CCID.S177448

Kadir NO. The impact of psoriasis on young Iraqi patients and the evaluation of logistic regression in this study. IAR J Clin Med Biochem. 2025;5(1):1-5. doi: 10.47310/iarjcmb.2025.v05i01.001.

Alnaqbi DKA, Alsennani F, Aloqaili DL, Alowaimer DB, Merashli DM, Kurban DM, et al. EE516 budget-impact model of adalimumab-biosimilar Sandoz in the management of autoimmune diseases in the Middle East. Value Health. 2022;25(12):S157. doi: 10.1016/j.jval.2022.09.758. DOI: https://doi.org/10.1016/j.jval.2022.09.758

Warren RB, Brnabic A, Saure D, Langley RG, See K, Wu JJ, et al. Matching-adjusted indirect comparison of efficacy in patients with moderate-to-severe plaque psoriasis treated with ixekizumab vs. secukinumab. Br J Dermatol. 2018;178(5):1064-1071. doi: 10.1111/bjd.16140. DOI: https://doi.org/10.1111/bjd.16140

Elmets CA, Korman NJ, Prater EF, Wong EB, Rupani RN, Kivelevitch D, et al. Joint AAD-NPF Guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures. J Am Acad Dermatol. 2021;84(2):432-470. doi: 10.1016/j.jaad.2020.07.087. DOI: https://doi.org/10.1016/j.jaad.2020.07.087

Kamata M, Tada Y. Efficacy and safety of biologics for psoriasis and psoriatic arthritis and their impact on comorbidities: A literature review. Int J Mol Sci. 2020;21(5):1690. doi: 10.3390/ijms21051690. DOI: https://doi.org/10.3390/ijms21051690

Glazer Levavi S, Maman R, Sherman S, Mimouni D, Pavlovsky L. Systemic biologic treatment for psoriasis in elderly patients. J Clin Med. 2025;14(13):4779. doi: 10.3390/jcm14134779. DOI: https://doi.org/10.3390/jcm14134779

Mason KJ, Barker JNWN, Smith CH, Hampton PJ, Lunt M, McElhone K, et al. Comparison of drug discontinuation, effectiveness, and safety between clinical trial eligible and ineligible patients in BADBIR. JAMA Dermatol. 2018;154(5):581-588. doi: 10.1001/jamadermatol.2018.0183. DOI: https://doi.org/10.1001/jamadermatol.2018.0183

Kaushik SB, Lebwohl MG. Psoriasis: Which therapy for which patient: Focus on special populations and chronic infections. J Am Acad Dermatol. 2019;80(1):43-53. doi: 10.1016/j.jaad.2018.06.056. DOI: https://doi.org/10.1016/j.jaad.2018.06.056

Foley P, Tsai TF, Rodins K, Hamadah IR, Ammoury A, Dayem HA, et al. Effectiveness and safety of secukinumab for psoriasis in a real-world clinical setting in the Asia-Pacific and Middle East regions: Results from the REALIA Study. Dermatol Ther (Heidelb). 2022;12(2):511-527. doi: 10.1007/s13555-021-00675-w. DOI: https://doi.org/10.1007/s13555-021-00675-w

Elmets CA, Lim HW, Stoff B, Connor C, Cordoro KM, Lebwohl M, et al. Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis with phototherapy. J Am Acad Dermatol. 2019;81(3):775-804. doi: 10.1016/j.jaad.2019.04.042. DOI: https://doi.org/10.1016/j.jaad.2019.04.042

AlQassimi S, AlBrashdi S, Galadari H, Hashim MJ. Global burden of psoriasis - comparison of regional and global epidemiology, 1990 to 2017. Int J Dermatol. 2020;59(5):566-571. doi: 10.1111/ijd.14864. DOI: https://doi.org/10.1111/ijd.14864

Mansouri Y, Goldenberg G. Biologic safety in psoriasis: review of long-term safety data. J Clin Aesthet Dermatol. 2015;8(2):30-42. PMID: 25741401.

Abbas O, Ammoury A, Abbadi M, Malek MA, Akkash L, Al-Chakharah K, et al. Guidelines for the topical treatment of psoriasis vulgaris in the Levant and Iraq area. Skinmed. 2015;13(6):445-453. PMID: 26861521.

Zweegers J, Otero ME, van den Reek JM, van Lümig PP, Driessen RJ, Kievit W, et al. Effectiveness of biologic and conventional systemic therapies in adults with chronic plaque psoriasis in daily practice: A systematic review. Acta Derm Venereol. 2016;96(4):453-458. doi: 10.2340/00015555-2276. DOI: https://doi.org/10.2340/00015555-2276

Rungapiromnan W, Yiu ZZN, Warren RB, Griffiths CEM, Ashcroft DM. Impact of biologic therapies on risk of major adverse cardiovascular events in patients with psoriasis: systematic review and meta-analysis of randomized controlled trials. Br J Dermatol. 2017;176(4):890-901. doi: 10.1111/bjd.14964. DOI: https://doi.org/10.1111/bjd.14964

Jabbar-Lopez ZK, Yiu ZZN, Ward V, Exton LS, Mohd Mustapa MF, Samarasekera E, et al. Quantitative evaluation of biologic therapy options for psoriasis: A systematic review and network meta-analysis. J Invest Dermatol. 2017;137(8):1646-1654. doi: 10.1016/j.jid.2017.04.009. DOI: https://doi.org/10.1016/j.jid.2017.04.009

Schaarschmidt ML, Herr R, Gutknecht M, Wroblewska K, Gerdes S, Sticherling M, et al. Patients' and physicians' preferences for systemic psoriasis treatments: A nationwide comparative discrete choice experiment (PsoCompare). Acta Derm Venereol. 2018;98(2):200-205. doi: 10.2340/00015555-2834. DOI: https://doi.org/10.2340/00015555-2834

American Academy of Dermatology. Psoriasis Clinical Guideline. Available at: https://www.aad.org/member/clinical-quality/guidelines/psoriasis

Strand V, Van den Bosch F, Ranza R, Leung YY, Drescher E, Zueger P, et al. Patient-reported outcomes in psoriatic arthritis patients with an inadequate response to biologic disease-modifying antirheumatic drugs: SELECT-PsA 2. Rheumatol Ther. 2021;8(4):1827-1844. doi: 10.1007/s40744-021-00377-x. DOI: https://doi.org/10.1007/s40744-021-00377-x

Pang M, Sun Z, Zhang H. Biologic DMARDs and targeted synthetic DMARDs and the risk of all-cause mortality in rheumatoid arthritis: A systematic review and meta-analysis. Medicine (Baltimore). 2022;101(32):e29838. doi: 10.1097/MD.0000000000029838. DOI: https://doi.org/10.1097/MD.0000000000029838

Wu B, Chen Q, Cao R, Zhu L, Zhu H. Comparative effectiveness of combined biologic agents versus standard therapies in the treatment of plaque psoriasis: a retrospective analysis. Front Med (Lausanne). 2024;11:1451069. doi: 10.3389/fmed.2024.1451069. DOI: https://doi.org/10.3389/fmed.2024.1451069

Abdulridha SH, Kadhim DJ, Abdul Razzak SA. Assessment of quality of life in a sample of iraqi patients with psoriasis. Iraqi J Pharm Sci. 2020;29(2):161–168. doi: 10.31351/vol29iss2pp161-168. DOI: https://doi.org/10.31351/vol29iss2pp161-168

Chakith MRS, Pradeep S, Gangadhar M, Maheshwari NC, Pasha S, Kollur SP, et al. Advancements in understanding and treating psoriasis: a comprehensive review of pathophysiology, diagnosis, and therapeutic approaches. PeerJ. 2025;13:e19325. doi: 10.7717/peerj.19325. DOI: https://doi.org/10.7717/peerj.19325

Ożóg MK, Derkacz A, Klimczak D, Winkler S, Wojciuch L. New therapies in the biological treatment of psoriasis: A review. Allergies. 2025;5(2):19. doi: 10.3390/allergies5020019. DOI: https://doi.org/10.3390/allergies5020019

Yi RC, Akbik M, Smith LR, Klionsky Y, Feldman SR. Therapeutic advancements in psoriasis and psoriatic arthritis. J Clin Med. 2025;14(4):1312. doi: 10.3390/jcm14041312. DOI: https://doi.org/10.3390/jcm14041312

Chan JJ. Psoriasis: an update on topical and systemic therapies. Aust Prescr. 2025;48(3):87-92. doi: 10.18773/austprescr.2025.026. DOI: https://doi.org/10.18773/austprescr.2025.026

Greenberg HL. Psoriasis treatment in 2025: More options, better outcomes. Pract Dermatol. 2025. Available: https://practicaldermatology.com/issues/august-2025/psoriasis-treatment-in-2025-more-options-better-outcomes/36706/