Monoclonal Agents for Moderate to Severe Psoriasis

Primary Recommendation

The American Academy of Dermatology recommends secukinumab as the superior first-line monoclonal antibody for moderate to severe plaque psoriasis, achieving 79% PASI 90 response at week 16 compared to 57.6% with ustekinumab, with this superiority maintained through 52 weeks 1

For patients with pure plaque psoriasis without psoriatic arthritis, the National Psoriasis Foundation suggests choosing secukinumab (IL-17A inhibitor) as the first-line treatment 1
For patients with concurrent psoriatic arthritis, the American College of Rheumatology recommends choosing ustekinumab (IL-12/23 inhibitor) as the first-line treatment 2, 3
For patients with a history of inflammatory bowel disease, the American Gastroenterological Association suggests choosing ustekinumab as the first-line treatment, as secukinumab may worsen IBD 1

The American Academy of Dermatology recommends a loading phase of 300 mg secukinumab subcutaneously at weeks 0, 1, 2, 3, and 4, followed by a maintenance dose of 300 mg every 4 weeks starting at week 8 1
For patients weighing ≤100 kg, the recommended dose of ustekinumab is 45 mg subcutaneously at weeks 0 and 4, then every 12 weeks 2
For patients weighing >100 kg, the recommended dose of ustekinumab is 90 mg subcutaneously at weeks 0 and 4, then every 12 weeks 2

The Centers for Disease Control and Prevention recommends mandatory screening for tuberculosis, active infection, and hepatitis B before initiating secukinumab or ustekinumab therapy 1, 3
The American Academy of Dermatology suggests assessing patients with a history of inflammatory bowel disease carefully before initiating secukinumab therapy 1

The American Academy of Dermatology reports that common adverse events with secukinumab include mucocutaneous candida infections, serious infections, neutropenia, and immunogenicity 1
The National Psoriasis Foundation states that ustekinumab is generally well-tolerated with no specific patterns of infection 2

The American Academy of Dermatology recommends combining secukinumab or ustekinumab with high-potency topical corticosteroids with or without vitamin D analogues to augment efficacy 1, 2
The National Psoriasis Foundation suggests combining ustekinumab with methotrexate, acitretin, or narrowband UVB phototherapy for improved efficacy 2

The Centers for Disease Control and Prevention recommends administering live attenuated vaccines at least 2-4 weeks before initiating secukinumab or ustekinumab therapy, and completing all indicated killed vaccines before starting therapy 1
The American Academy of Dermatology suggests administering pneumococcal vaccine, annual influenza vaccination, and COVID-19 vaccines as soon as eligible 1