Before Calling a Psoriasis Biologic a Failure, Consider Treatment Persistence

During a case-based presentation at the Masterclasses in Dermatology NP/PA Institute, Victor Czerkasij, DNP, DCNP, FNP-C, CWCP, described a 45-year-old woman with severe plaque psoriasis whose treatment course demonstrated how the clinical challenge can shift from selecting an effective therapy to maintaining patient engagement.

The patient initially presented with psoriasis affecting approximately 35% of her body surface area (BSA) and an Investigator Global Assessment (IGA) score of 4. Her scalp, arms, and legs were involved, with particularly severe disease on the abdomen and back. She also experienced substantial discomfort and quality-of-life burden.

Before biologic therapy, the patient received methotrexate without adequate long-term control; systemic corticosteroids; tanning booth or ultraviolet exposure; and topical therapies, including triamcinolone, clobetasol, and briefly, calcipotriene.

Her subsequent biologic treatment course produced improvement that repeatedly proved difficult to sustain. Adalimumab initially improved her disease, but symptoms worsened by approximately 6 months. Ustekinumab produced improvement following the loading dose that was not maintained. Ixekizumab similarly failed to provide durable control.

Two punch biopsies reconfirmed classic plaque psoriasis. Treatment options were also influenced by patient preferences. Brodalumab was discussed, but the patient was uncomfortable with its Risk Evaluation and Mitigation Strategy program. She was reluctant to use apremilast because of concerns about depression and neuropsychiatric effects.

A turning point came with guselkumab, which was administered in the office with close follow-up. The patient achieved complete clinical clearance that persisted for approximately 1 year.

The response demonstrated that her psoriasis was “highly treatment responsive when therapy was consistently received,” according to Dr Czerkasij.

The pattern then changed. Scheduled office injections became inconsistent, and the patient began missing visits before eventually stopping guselkumab administration. Importantly, no pharmacologic loss of response had been demonstrated before treatment was interrupted.

“The clinical problem had shifted from drug selection to treatment persistence and engagement,” Dr Czerkasij noted.

The case provided the basis for a nurse practitioner (NP)/physician assistant (PA)-focused framework for evaluating apparent biologic failure. Dr Czerkasij recommended first reassessing the diagnosis, disease severity, and phenotype and verifying treatment exposure, including dosing, loading, and persistence.

Clinicians should also objectively measure disease using BSA, IGA or Physician Global Assessment, photographs, and quality-of-life measures. Potential modifiers, including obesity, smoking, medications, infection, and psoriatic arthritis, should be considered.

Finally, NP and PAs should explore barriers, such as fear, cost, logistics, beliefs, and mental health, and develop strategies to support persistence through shared planning, reminders, support, and follow-up.

The case underscores that when psoriasis stops responding as expected, the next step may not always be another therapy. Determining whether the patient consistently received an effective treatment can be equally important before labeling a biologic a failure.

Reference

Czerkasij V. Complex medical dermatology cases. Presented at: Masterclasses in Dermatology NP/PA Institute; September 26–27, 2026; New York City, NY.