Drug Stratification Based on Real-World Evidence in Psoriasis: A Narrative Review

Over the past two decades, numerous highly effective biological treatments have been developed for patients with moderate-to-severe psoriasis. As a result of more effective therapies, treatment goals have shifted from a 50% to a 90% reduction in psoriasis area and severity index. Although randomized controlled trials provide some insight, they often include only a subset of patients, have short durations, and do not compare different treatments. Many patients respond well to these new treatments; however, some do not respond at all, whereas others experience a loss of effectiveness after an initial response. No definitive guidelines on the best time to start treatment or on how to choose the most suitable treatment for an individual patient have yet been established. Furthermore, it remains uncertain whether optimal treatment or specific therapy reduces the risk of developing comorbidities. Real-world data have revealed adverse effects, such as tuberculosis reactivation with tumor necrosis factor inhibitors, worsening of inflammatory bowel disease with interleukin-17 inhibitors, and potential cardiovascular events associated with particularly interleukin-12/23 inhibition. Studies from both clinical trials and real-world settings have also shown that patients with high body mass index, smokers, older individuals, and those with prior biological treatments tend to have poorer treatment outcomes. Recently, studies have indicated that genetic markers such as HLA-C*06:02, initial treatment response, and post-initiation drug concentration levels can predict treatment response. The integration of genetic markers, clinical data, and advanced technologies may aid in developing more personalized treatment plans for patients in the future.