Comprehensive management: Paradigm shift of care for psoriasis

Psoriasis has a global prevalence ranging from 0.14% to 1.99%. This disease imposes an escalating burden and is strongly associated with multiple comorbidities.[1] Traditional therapies for psoriasis comprise a diverse range of treatments, including topical agents, phototherapies, and systemic medications. Several models and algorithms, such as combination, rotational, and sequential therapies, have been proposed to optimize disease management by minimizing reliance on single agents, mitigating toxicity, and adapting to the chronic nature of psoriasis.[2] The traditional management paradigm focuses on alleviating cutaneous manifestations. Therapeutic modalities are limited to topical and conventional immunosuppressive agents, with broad mechanisms of action and adverse effects. Consequently, this approach is constrained by the nature of reactive management rather than by long-term disease modification, neglecting systemic inflammatory processes, comorbidities, and psychosocial impacts. In recent years, psoriasis has been increasingly recognized as a systemic inflammatory disease with visible skin manifestations that reflect broader effects on joints and other comorbidities. This evolving understanding is reshaping patient management and therapeutic strategies to address cutaneous symptoms and systemic comorbidities.[3] Contemporary treatments for psoriasis use advanced biologics that target key inflammatory cytokines, such as tumor necrosis factor-alpha, interleukin (IL)‑17A, and IL-23, to manage moderate-to-severe disease. Novel small oral molecules have emerged as promising therapeutic agents for psoriasis. These therapeutic innovations not only improve cutaneous outcomes but also address the systemic inflammatory burden and associated comorbidities.[4] With the development of new understanding and treatment modalities for psoriasis, a paradigm shift has become necessary. Holistic management has been proposed, focusing on understanding how various complications influence the overall health of patients.[5] However, understanding still needs to be further developed to enhance psoriasis management toward highly individualized regimens that combine rapid control with long-term maintenance, and the chronic, systemic nature of psoriasis needs to be recognized.[2] It is appropriate to propose a new management paradigm that emphasizes a comprehensive approach integrating four key dimensions, which will be discussed later [Figure 1].Figure 1: Framework for the comprehensive management of psoriasis. This figure outlines a multidimensional approach to psoriasis management, organized into four core components: whole-system treatment, including biological therapies and oral small molecules, to target systemic inflammation; holistic management for comorbidities: Emphasizing screening for comorbidities, multidisciplinary team (MDT) care; lifespan care: Focuses on treat-to-target strategy, continuous treatment, and long-term risk management to address evolving patient needs; comprehensive decision-making: Prioritizing patient-centered strategies to align care with individual preferences, considering all aspects of the patient. The model integrates medical, psychological, and social elements to optimize outcomes across all stages of psoriasis.Biologics target specific immune pathways (e.g., IL-23 and IL-17) to offer sustained remission and reduce systemic inflammation. Overall, the new treatment demonstrated higher efficacy than traditional drugs, making Psoriasis Area and Severity Index (PASI) 90/100 (90% or 100% improvement in a patient’s psoriasis severity score relative to baseline) an achievable and new standard treatment target for psoriasis.[6] The systemic nature of biologics and small molecules makes them suitable for the treatment of systemic inflammation. In addition to psoriasis, many of these drugs have been approved for multiple indications, such as psoriatic arthritis.[7] The successful treatment effect of the targeting drugs for psoriasis-related systemic inflammation has led to the development of the concept of “psoriatic disease.”[8] Management for a psoriatic disease often means identifying the systemic problem of psoriasis and treating it with proper systemic drugs, that is, a “whole-system treatment”. Psoriasis is associated with a broad range of systemic comorbidities, including psoriatic arthritis and gastrointestinal and cardiometabolic diseases. These associations likely arise from shared inflammatory pathways, genetic predispositions, and common risk factors, underscoring the need for comprehensive care.[9] Routine examinations for metabolic syndrome, hypertension, and arthritis are recommended.[10] Early detection and treatment of psoriatic arthritis in patients with psoriasis are crucial for preventing joint destruction and disease progression. Dermatologists collaborate with rheumatologists, cardiologists, and other professionals to improve the outcomes of patients with psoriasis.[10] As psoriasis is a lifelong disease, clinical decisions must be integrated with long-term considerations. To control the current disease, we aim to clear skin lesions. An absolute PASI score of ≤2 has been recommended as a robust and practical treatment target for psoriasis.[11] For long-term care, we aim to maintain efficacy. Continuous therapy with targeted biological agents is increasingly recommended for sustained inflammatory control in psoriasis treatment. A recent study revealed that continuous biological treatment over five years demonstrated a consistent efficacy and favorable safety profile.[12] For future control of the disease and comorbidities, we attempted to identify risk factors for early prediction and intervention. Integrative omics analyses of psoriasis gene signatures in blood and skin have been performed to identify predictive biomarkers of treatment responses and comorbidities. Future psoriasis management may integrate multimode data and intelligent technologies to predict the disease course and comorbidity risk.[13] As a result of understanding the above aspects, it would be natural to require comprehensive consideration when making clinical decisions for the care of all parts of psoriatic disease. Patient-centered care is crucial, as it addresses the multifaceted impairments experienced by patients.[14] The World Health Organization’s people-centered model of care emphasizes adopting the perspective of affected individuals and their environment, placing patients at the center of care.[14] Patient/physician goals can be determined by considering factors such as patient-reported outcomes, quality of life, satisfaction, communication, and adherence.[15] Access to new drugs significantly affects treatment options and adherence. The survival rates of patients treated with biological medications for psoriasis vary significantly and are influenced by drug availability.[16] Patients in some countries experience significantly more severe diseases and have less access to biological therapies.[17] Challenges such as treatment failure, high costs, and the need for more effective therapies for specific subtypes of psoriasis underscore the need for future innovations.[18] Dermatologists play a crucial role in identifying the risks and early signs of comorbidities, as they are often the primary healthcare providers for patients with psoriasis. However, awareness and screening for comorbidities among clinicians remain inadequate, with studies showing possible underdiagnosis. Improved knowledge and skills regarding comorbidity management are essential for dermatologists to provide timely interventions.[19] A multidisciplinary team (MDT) approach is essential, given the wide range of comorbidities associated with psoriasis.[10] However, comprehensive MDT care for patients with psoriasis is lacking, and many patients receive inadequate treatment despite the availability of guidelines and therapies.[20] Barriers to optimal multidisciplinary care include physician knowledge and willingness gaps, patient non-adherence, administrative factors, and external factors such as reimbursement issues.[20] Psoriasis needs lifelong management. However, the long-term efficacy of these new treatment modalities remains unclear owing to the scarcity of long-term efficacy data.[21] Loss of efficacy, treatment failure, or drug resistance is not uncommon.[22] Long-term safety data are limited. This limitation is particularly evident for newer biologics.[21] The economic burden of psoriasis is substantial. Therefore, disparities exist, particularly among low-income populations. According to a study by the National Psoriasis Foundation, severe psoriasis is significantly associated with a higher probability of low household income.[23] New medications targeting distinct mechanisms of the underlying inflammatory processes (e.g., receptor-related orphan receptor gammat inhibitors, sphingosine-1-phosphate receptor 1 antagonists, and heat shock protein 90 inhibitors) are in development. Recently, an oral IL-23-receptor antagonist peptide demonstrated superior efficacy to a placebo for moderate-to-severe plaque psoriasis.[24] New technologies such as telemedicine have demonstrated a potentially valuable adjunct effect in psoriasis management. Ongoing studies are evaluating the role of artificial intelligence in managing psoriasis and detailing its applications in diagnosis, treatment prediction, and patient management.[25] The evolution of psoriasis care will be defined by the refinement and expansion of comprehensive management, a multidimensional framework integrating systemic therapies, comorbidity vigilance, lifespan strategies, and patient-centered decision-making. Future innovations will further entrench these comprehensive principles. Equitable access reforms, such as biosimilar adoption, tiered pricing, and policy integration, will dismantle socioeconomic barriers and ensure that comprehensive care reaches underserved populations. By harmonizing systemic concepts, precision medicine, preventive health, and patient empowerment, comprehensive management will transition from an aspirational model to a standard of care, transforming psoriasis into a condition of sustained wellness. Funding This work was supported by a grant from the Beijing Hospitals Authority’s Ascent Plan (No. DFL20240901) and Capital’s Funds for Health Improvement and Research (No. 2024-2-2243). Conflicts of interest The author has received honoraria for lectures during the past 36 months from Novartis, Johnson & Johnson, Sanofi, AbbVie, Pfizer, Eli Lilly, Bristol-Myers Squibb, Hengrui Pharmaceuticals, and Genrix Biopharmaceuticals. Declaration of generative AI and AI-assisted technologies in the writing process Paperpal and DeepSeek were used to improve language and readability during the preparation of this study. After using this tool/service, the author reviewed and edited the content as required and took full responsibility for the content of the publication.