A “Step-Down” Approach May Be More Effective for Younger Patients with Psoriasis

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Younger patients (< 45 years) with psoriasis may benefit from earlier treatment approaches with biological therapies, according to new real-life data.¹ This “step-down” approach rather than a “step-up” strategy can improve the overall number of patients who respond to treatment.

A total of 205 patients with psoriasis from the Belgian Psoriasis Registry, which was established in 2019, were included. The median age was 53 years with a mean body mass index of 27.50 kg/m². Most participants were male and Caucasian, 60.5% and 66.8% respectively.

The study was split into 2 parts; a retrospective portion for those who were new to the registry (n = 104) and a prospective portion for those who were already in the registry (n = 101). Follow-up consultations took place at Erasmus Hospital in Brussels. About 40% had a short-term follow-up before 35 weeks while 60% had a long-term follow-up after 40 weeks.

Investigators collected data on lifestyle and socio-demographic changes, disease characteristics, treatment plan specifics, and other comorbidities. Patients who were responsive to treatment had a decrease in Psoriasis Area Severity Index (PASI) score that was more than 75% between baseline and follow-up.

About 47% of patients reached PASI75. Of these short-term results, 50% of patients were treated with biologics, 30.5% used systemic conventional therapies, and 32.5% were on topicals and/or phototherapy.

After the long-term follow-up, the patients receiving biologic therapy had an increased response (57%). Conventional systemic therapy responded more slowly but did eventually reach the same long-term level of efficacy (55.5%). Patients receiving topicals/phototherapy also saw a moderate increase in response (50%).

It’s important to note that for patients with mild disease severity, topical treatments may initially be effective and cheaper than biologics. However, according to the researchers, “many patients discontinue their treatment due to the lack of efficacy and the impact on their quality of life so the overall costs may not be so different from other treatment modalities.”

There was no significant difference between PASI75 and PASI90 results. Despite this, patients who were treated shortly after the first lesions appeared had better responses than those who waited (p < 0.0001). Interestingly, rapid biologic therapy had better short-term results while treatment with systemic conventional therapy had better long-term response. This aligns with previous randomized controlled trials, STEPIn and GUIDE, that showed prompt initiation of biologic therapy was associated with improved treatment outcomes.²

Further analysis demonstrated that younger patients responded faster to treatment versus older patients. The median age of short-term responders was 36.9 while the median age of participants that had no response was 56.4.

Patients in Belgium are typically treated with a “step-up” strategy in which to be eligible for biologics, patients must have a PASI score over 10 or a BSA > 10% after already trying phototherapy and conventional systemic therapy.³ According to the authors, this method is not cost-effective due to the frequent changes in medication and the increase in travel for clinic visits. 

The research proposes a “step-down” approach that counteracts this, in which patients begin with the biological therapy for a limited time and then reduce dosing frequency when remission is reached. A proposed supplemental follow-up form would help to collect data. This creates better results in disease management while also promoting more monetary flexibility and improving quality of life. 

Although more research is needed to confirm the cost-effectiveness of this strategy in Belgium specifically, this new approach could greatly improve patient care for those with psoriasis, especially those younger than 45.

References

1. Behlock Y, Dandoy C, Willaert F, et al. Early Use of Beneficial Biological Therapy on Younger Psoriasis Patients: Could a 'Step-Down' Therapy Approach Be More Effective?. Int J Dermatol. Published online February 23, 2025. doi:10.1111/ijd.17704

2. Ben Abdallah, H., Emmanuel, T., Bregnhøj, A., Johansen, C., & Iversen, L. (2022). Early intervention and disease memory in psoriasis: A literature review. JEADV Clinical Practice, 1(4), 307-316.

3. Riedl E, Mrowietz U, Hill B J, Sapin C, Warren R. Subgroup Analyses by European Country-Specific Reimbursement Requirements Confirm Efficacy for Ixekizumab in Psoriasis. J Drugs Dermatol. 2022;21(6):659-667. doi:10.36849/JDD.6620