Biologic Head-to-Head Psoriasis Trials Show Nail, Skin Clearance With Ixekizumab

Patients with psoriasis treated with ixekizumab (Talz, Eli Lilly) had higher rates of simultaneous complete skin and nail clearance compared with those treated with etanercept, ustekinumab, and adalimumab. This is according to a post hoc analysis published in Dermatology and Therapy¹of 5 head-to-head trials.

“Ixekizumab is an excellent treatment for nail psoriasis, which is not surprising because it is also effective in psoriatic arthritis,” stated lead author Boni Elewski, MD, speaking to Rheumatology Network. Elewski is a professor of dermatology at the University of Alabama. “This study confirms the efficacy of ixekizumab in psoriatic arthritis and skin and nail psoriasis.”

Nail psoriasis is associated with physical impairment, pain, anxiety and/or depression, and quality of life impairments. In patients with psoriasis, the lifetime incidence of nail psoriasis is as high as 90%, with up to 27% of patients having nail psoriasis at any given time and is more prevalent in patients with psoriatic arthritis. Ixekizumab, which is a high-affinity monoclonal antibody that targets interleukin-17A, is approved for use in patients with moderate-to-severe plaque psoriasis, genital psoriasis, and psoriatic arthritis. Complete psoriasis clearance should include nail psoriasis resolution.

In this study, Elewski and colleagues compared the efficacy of ixekizumab in the simultaneous clearance of skin and nail psoriasis with 4 other biologics: etanercept, guselkumab, ustekinumab, and adalimumab.

The study included data from the following 5 head-to-head trials: IXORA-R, IXORA-S, UNCOVER-2, UNCOVER-3 and SPIRIT-H2H, which have shown the long-term efficacy and safety of ixekizumab for up to 5 years. Patients had moderate-to-severe psoriasis, with or without psoriatic arthritis, with nail psoriasis at baseline. Psoriasis Area and Severity Index (PASI) 100 represented complete skin clearance, and Nail Psoriasis Severity Index (NAPSI) 0 represented complete nail clearance in all trials apart from IXORA-R, when the Physician's Global Assessment of Fingernail Psoriasis (PGA-F) 0 was used.

At week 12, ixekizumab achieved greater simultaneous skin and nail complete clearance than etanercept (UNCOVER-2 and UNCOVER-3: p < 0.001). Across all 5 trials, ixekizumab achieved simultaneous skin and nail clearance in 28.6% to 45.9% of patients by week 24 that was maintained up to week 52 in 40.5% to 51.4% of patients. Ixekizumab showed greater simultaneous clearance than ustekinumab (p < 0.001) and adalimumab (p = 0.006) at week 24 and week 52 (p < 0.001 and p = 0.007, respectively). Ixekizumab achieved numerically greater, but not statistically significant greater, simultaneous complete clearance compared with guselkumab at week 24.

As nail psoriasis is not included in the PASI score, “therapeutic goals for treatments should look beyond PASI 100 and consider their efficacy in treating challenging body areas such as nails,” concluded investigators. There is a need for physicians to personalize treatments for individual patients, and “to consider the efficacy of treatments not only in clearing skin psoriasis, but also in clearing nail psoriasis.”

Reference:

Elewski, B.E., Blauvelt, A., Gallo, G. et al. Simultaneous Nail and Skin Clearance in Ixekizumab Head-to-Head Trials for Moderate-to-Severe Psoriasis and Psoriatic Arthritis. Dermatol Ther (Heidelb) (2022). https://doi.org/10.1007/s13555-022-00704-2