Oral Therapies in Focus: Where Pills Fit in a Biologic-Dominated Psoriasis Landscape

At the Fall Clinical 2025 session, “Where Oral Therapies Fit in an Injectable Landscape for Psoriasis Management,” Tiffany Mayo, MD, MSc; Linda F. Stein Gold, MD; and Elizabeth (Lisa) A. Swanson, MD, explored how the oral treatment landscape is expanding and where it meaningfully fits alongside injectables. The panel addressed emerging oral IL-23 inhibitors, the durability of current biologics, and patient preferences, framing the discussion around evolving treatment goals like on-treatment remission and real-world clinical needs.

Dr Mayo opened with a review of how treatment targets have evolved. In 2017, an acceptable response was defined as body surface area (BSA) ≤3% within 3 months. Today, the National Psoriasis Foundation’s on-treatment remission definition—BSA 0% sustained for 6 months—reflects both the strength of available therapies and rising expectations from patients and providers.

“These are stringent treatment targets, but they are very achievable,” Dr Mayo said. “They align with what patients want: better outcomes, improved satisfaction, and reduced systemic inflammation.”

Dr Swanson highlighted several updates for injectable IL-23 inhibitors:

• Guselkumab: Recent data from the APEX study confirmed radiographic progression prevention in psoriatic arthritis, achieving statistical significance at week 24. Pediatric approval was also granted down to age 6 years, based on the PROTOSTAR study. “It’s our fifth biologic approved for kids and a great option with infrequent dosing,” she said.
• Tildrakizumab: Dr Mayo noted that while efficacy is solid (Psoriasis Area and Severity Index 90 in ~70% at week 28), its strength lies in durability and safety. “Adverse events were comparable to placebo,” she noted. Data also support use in difficult sites like the scalp and nails, with improvements in Investigator’s Global Assessment and Nail Psoriasis Severity Index by week 20. Tildrakizumab also offers physician-administered injections, a benefit for Medicare Part B coverage and compliance.
• Risankizumab: Dr Stein Gold shared 5-year data showing consistent performance, regardless of statistical modeling approach. Compared with secukinumab, risankizumab demonstrated greater durability past 52 weeks. “We’ve become very comfortable using IL-23 inhibitors to keep patients under control safely and effectively,” she said.

The panel shifted to the central topic: oral therapies. With multiple IL-23 injectables showing durable response and favorable safety, attention is turning toward oral IL-23 agents currently in development.

“This is very exciting,” said Dr Mayo. “We know the IL-23/Th17 axis is central to psoriasis, and oral therapies targeting this pathway could combine biologic-level efficacy with the convenience of a pill.”

Dr Stein Gold challenged the assumption that fewer injections equal higher satisfaction. In recent studies, when patients and providers were asked about preferred route of administration, both groups favored oral therapy over injectables—provided efficacy and safety were comparable.

“Patients said, if you give me something with the efficacy of my shot and the safety of a pill, 9 out of 10 would switch,” she said.

Even among patients currently happy with injectables, needle phobia and stress about upcoming doses remain barriers. “It may be only 4 times a year, but for some patients, that’s 4 times too many,” she added.

The panel emphasized individualized care where oral therapies could fill key gaps:

• Patients with moderate disease who prefer not to inject
• Pediatric patients aging into systemic therapy
• Patients with site-specific disease (e.g., scalp, nails) needing easier access to treatment
• Needle-phobic patients or those with difficult access to infusion or injection services

The speakers agreed that special sites and pediatric needs represent unmet clinical areas where more oral options would be welcome.

During an interactive poll, attendees were asked what they considered the greatest unmet need in psoriasis care. While answers varied, 3 themes emerged:

• Better topical options
• Oral therapies with high efficacy and low risk
• Therapies for special sites

Dr Swanson said, “Special sites are a big one for me,” whereas Dr Mayo prioritized pediatric needs. Dr Stein Gold underscored the need for safer, more effective orals. “We’ve made incredible progress, but we still need options that hit all these checkboxes,” she said.

Patients with localized psoriasis prefer topicals. But those with moderate-to-severe disease showed a clear preference for oral medications, especially if they could reduce office visits and side effects.

“The assumption that a few injections per year is enough is not always true,” Dr Stein Gold concluded. “We need to meet patients where they are, and for many, that’s oral therapy.”

As the therapeutic landscape broadens, dermatologists must consider not just what therapy works, but how patients want to receive it. With oral IL-23 inhibitors nearing approval, the field may soon gain another tool—one that aligns with evolving expectations, improves adherence, and expands access for those previously limited by injectable-only options.

Reference
Mayo T, Stein Gold L, Swanson E. Where oral therapies fit in an injectable landscape for psoriasis management. Presented at: 2025 Fall Clinical Dermatology Conference. October 23–26, 2025; Virtual.