Using biologic therapies as first-line systemic treatment for psoriasis: a cohort study following the target trial emulation framework using data from the British Association of Dermatologists Biologics and Immunomodulators Register

Phan, Duc Binh, Laws, Philip, Smith, Catherine H, Griffiths, Christopher E M, Kirby, Brian, Hughes, Olivia, Rogers, Gabriel, Alabas, Oras A, Lunt, Mark, Warren, Richard B and Yiu, Zenas Z N 2026. Using biologic therapies as first-line systemic treatment for psoriasis: a cohort study following the target trial emulation framework using data from the British Association of Dermatologists Biologics and Immunomodulators Register. British Journal of Dermatology 195 (1) , pp. 58-67. 10.1093/bjd/ljag098

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Abstract

Background: Current treatment pathways for moderate-to-severe psoriasis in the UK and the Republic of Ireland direct initiation of targeted biologic immunomodulators when conventional systemic drugs are ineffective or not tolerated. Starting biologics early in the treatment pathway may modify disease course and improve short- and long-term outcomes. Objectives: To compare the effectiveness and risk of incident comorbid conditions over 5 years when initiating a biologic as the first systemic treatment vs. the current standard of care, in which the patients started with a conventional non-biologic systemic therapy with possible subsequent switch to biologics. Methods: This study applied the target trial emulation framework using data from the British Association of Dermatologists Biologics and Immunomodulators Register. Adults (aged ≥ 18 years) with moderate-to-severe psoriasis [baseline Psoriasis Area and Severity Index (PASI) ≥ 10] and no prior systemic therapy were included. Five-year trajectories of PASI and Dermatology Life Quality Index (DLQI) were modelled using mixed-effects repeated-measures models. The probability of complete skin clearance (PASI 0) and the risk of developing long-term comorbidities (cardiovascular, hepatic, neoplastic, metabolic, mental health or musculoskeletal disorders, and incident psoriatic arthritis) were estimated using marginal structural models with stabilized inverse probability weighting to adjust for baseline and time-varying confounding. Results: We included 3702 patients: 3368 followed the current standard of care and 334 initiated a biologic as first-line systemic therapy. At 5 years, the modelled mean PASI was 4.7 [95% confidence interval (CI) 4.0–5.4] for standard of care and 2.0 (95% CI 1.2–2.7) for biologic initiators; DLQI were 5.6 (95% CI 4.2–7.0) and 3.5 (95% CI 1.3–5.7), respectively. The cumulative rate of achieving PASI 0 was 32.2 vs. 58.6%, with a higher likelihood of PASI 0 for biologic initiators [hazard ratio (HR) 2.85, 95% CI 2.34–3.47]. The cumulative risk of chronic comorbidities was lower among biologic initiators (47.5 vs. 54.3%; HR 0.72, 95% CI 0.58–0.89), with lower risks of mental health (HR 0.64, 95% CI 0.44–0.94) and hepatic (HR 0.54, 95% CI 0.38–0.76) disorders. Conclusions: Initiating biologics as the first systemic therapy was associated with better clinical outcomes compared with standard stepwise approaches. Our results support reconsideration of existing pathways to allow earlier use of biologics.

Item Type:	Article
Date Type:	Publication
Status:	Published
Schools:	Schools > Psychology
Publisher:	Oxford University Press
ISSN:	0007-0963
Date of First Compliant Deposit:	7 July 2026
Date of Acceptance:	10 March 2026
Last Modified:	07 Jul 2026 13:15
URI:	https://orca.cardiff.ac.uk/id/eprint/188026

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