Key takeaways:
Biologics for moderate-to-severe psoriasis now span four major classes — TNF inhibitors, IL-12/23 inhibitors, IL-17 inhibitors, and IL-23 inhibitors — with newer-generation agents consistently delivering higher rates of skin clearance.
No single biologic is right for every patient. The best choice depends on disease severity, comorbidities (especially psoriatic arthritis or IBD), patient lifestyle, and what insurance will actually cover.
Biosimilars are reshaping the access landscape. They carry the same efficacy and safety standards and can meaningfully lower cost.
Psoriasis affects roughly 3% of the U.S. population and carries a substantial quality-of-life burden that extends beyond the skin. People with psoriasis are at increased risk for cardiovascular disease, metabolic syndrome, and psoriatic arthritis. Biologics target the specific immune pathways driving this systemic inflammation, which is precisely why they work so well. It’s also why matching the right drug to the right patient profile matters so much.
With more than a dozen FDA-approved biologics now available for psoriasis — and more on the way — the hardest part of managing moderate-to-severe disease is often not whether to start a biologic, but figuring out which one. The short answer is that there is no universal first choice. The long answer involves understanding what the guidelines say, how a patient's comorbidities narrow the field, and what will actually make it through insurance authorization.
Here is a practical, class-by-class breakdown to help guide those conversations.
What are the options?
Approved biologics for psoriasis fall into four classes based on their mechanism of action. Within each class, there are meaningful differences in efficacy, dosing frequency, and which comorbidities they cover.
TNF inhibitors
TNF inhibitors were the original biologics for psoriasis. They include:
They remain useful, particularly for patients with concurrent psoriatic arthritis or inflammatory bowel disease (IBD), and they now have robust long-term safety data. Their main limitation is that they achieve lower rates of skin clearance than newer-generation agents. Their dosing schedule may also be a drawback for patients. Many of them are dosed every 1 to 2 weeks, and Remicade requires an infusion.
Adalimumab biosimilars have also been widely available since 2023, making this class significantly more affordable.
IL-12/23 inhibitors
The first and only IL-12/23 inhibitor for psoriasis treatment is Stelara (ustekinumab). This medication targets a shared subunit of both IL-12 and IL-23. It has a favorable dosing schedule (every 12 weeks after induction), is approved for Crohn's disease and ulcerative colitis in addition to psoriasis, and has a strong long-term safety record.
Biosimilars for ustekinumab began entering the market in 2025. Examples include:
An unbranded version of ustekinumab is also available, making it a more cost-competitive option than it has been historically.
IL-17 inhibitors
IL-17 inhibitors represent a major step forward in efficacy. After an initial loading phase, these medications tend to be dosed less frequently than TNF inhibitors, but more often than IL-12/23 inhibitors. IL-17 inhibitors include:
A 2024 meta-analysis found that IL-17 inhibitors had the fastest time to achieving skin clearance of any biologic class. The tradeoff? IL-17 inhibitors carry a higher rate of Candida infections and should be used cautiously in patients with active IBD, as they can worsen intestinal inflammation.
There are no IL-17 inhibitor biosimilars currently available. This makes IL-17 inhibitors a more expensive choice for many patients.
IL-23 inhibitors
Icotyde (icotrokinra) is the first oral IL-23 inhibitor for psoriasis. The FDA approved it in March 2026 for treatment of moderate-to-severe plaque psoriasis for people ages 12 and older. This may be a good option for patients who are avoiding needles, but because it’s new, there isn’t as much safety and efficacy data.
Injectable IL-23 inhibitors include:
A large meta-analysis found that IL-23 inhibitors demonstrated the most favorable outcomes of all biologic classes. Dosing intervals are among the most patient-friendly available, as well. IL-23 inhibitors are generally well tolerated and have a low adverse event profile.
There are also no biosimilars available for IL-23 inhibitors, as all agents remain under patent protection.
What do the guidelines say?
The Joint AAD-NPF Guidelines are the primary reference for this decision. Here are key takeaways from the guidelines:
Biologics are recommended for moderate-to-severe disease. The threshold for biologic therapy is typically defined as involvement of more than 10% body surface area, a PASI (Psoriasis Area Severity Index) score of 10 or higher, or psoriasis affecting high-impact areas (face, scalp, genitals, palms, soles) that causes significant functional impairment.
There is no single preferred first-line agent. The guidelines recommend offering any currently approved biologic as first-line therapy, with the expectation of substituting a different agent if the first fails. This reflects the reality that drug selection is highly individualized.
Comorbidities matter a lot. For example:
Psoriatic arthritis: TNF inhibitors or IL-17 inhibitors are recommended as first-line options in patients with psoriatic arthritis.
Inflammatory bowel disease: Patients with IBD should avoid IL-17 inhibitors. Etanercept (a TNF inhibitor) is not recommended for patients with IBD either. Ustekinumab and IL-23 inhibitors are safer options in the IBD population.
Congestive heart failure: For patients with congestive heart failure, infliximab should be avoided (especially at higher doses).
Continuous therapy outperforms intermittent therapy. The guidelines are explicit that stopping and restarting biologics is not generally recommended. Consistent treatment tends to maintain and even improve skin clearance over time. Gaps, meanwhile, can reduce effectiveness and complicate insurance coverage.
Screening before starting is nonnegotiable. All patients should be screened for latent TB, hepatitis B, and up-to-date vaccinations before biologic initiation. Live vaccines should not be administered while a patient is on a biologic.
Cost and access considerations
The sticker price of biologic therapy for psoriasis is high. Annual costs for branded agents can reach nearly $80,000. But in practice, almost no patient pays list price. A combination of insurance, manufacturer copay programs, and patient assistance programs closes much of the gap, but access is still far from seamless.
Here are a few practical realities to know:
Prior authorization is nearly universal. Most payers require documentation of moderate-to-severe disease and often a trial of one or more conventional therapies (methotrexate, phototherapy, or apremilast) before approving a biologic. Knowing your payer's requirements saves time for both your team and your patients.
Biosimilars are changing the math. Adalimumab biosimilars arrived on the market in mid-2023, and ustekinumab biosimilars became available beginning in 2025. Biosimilars undergo a rigorous FDA approval process and must demonstrate no clinically meaningful differences in efficacy, purity, or safety from the reference product. For patients whose insurance prefers a biosimilar, there is no clinical reason to avoid them.
Formulary placement drives real-world access. The most effective drug on paper is not always the most accessible. IL-17 and IL-23 inhibitors tend to sit in higher formulary tiers, which means prior authorization burden is greater and patient cost-sharing can be significant.
The bottom line
Choosing a biologic for psoriasis is not as complicated as the crowded market might suggest. It can help to start with disease severity and location, then consider comorbidities, particularly psoriatic arthritis and IBD, which will immediately rule certain agents in or out. Factor in dosing frequency, the patient’s preferences, and what the formulary will support before committing to a plan.
For most patients with moderate-to-severe plaque psoriasis, IL-17 or IL-23 inhibitors are the current clinical standard. For active psoriatic arthritis, TNF inhibitors and IL-17 inhibitors remain first-line. For IBD, look to ustekinumab or a selective IL-23 inhibitor.
The treatment goal has shifted from managing psoriasis to clearing it, and with today's biologic toolkit, that's achievable for most patients.
Why trust our experts?
References
Aggarwal, P., et al. (2024). IL-17 and IL-23 inhibitors have the fastest time to meaningful clinical response for plaque psoriasis: A network meta-analysis. Journal of Clinical Medicine.
Belinchon Romero, I., et al. (2022). PASI 100 response rates in moderate to severe psoriasis: a systematic literature review and analysis of clinical practice guidelines. Journal of Dermatological Treatment.
Contreras, B. (2025). Psoriasis drug costs have risen, but less expensive options are out there. Managed Healthcare.
Gisondi, P., et al. (2025). Biosimilars for the treatment of moderate to severe chronic plaque psoriasis. Psoriasis: Targets and Therapy.
Jeremias, S. (2025). 3 ustekinumab biosimilars launch on US market. The Center for Biosimilars.
Johnson & Johnson. (2026). FDA approval of Icotyde (icotrokinra) ushers in new era for first-line systemic treatment of plaque psoriasis with a targeted oral peptide. PR Newswire.
Menter, A., et al. (2019). Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. JAAD.
Sawyer, L. M., et al. (2019). Assessing the relative efficacy of interleukin-17 and interleukin-23 targeted treatments for moderate-to-severe plaque psoriasis: A systematic review and network meta-analysis of PASI response. PLOS One.
