10.5826/dpc.1401a58
Introduction: Obesity plays a major role in the development of many inflammatory disorders including psoriasis.
Objectives: We aimed to demonstrate how treatment responses change according to body mass index among patients with psoriasis.
Methods: In our study, Psoriasis Area and Severity Index (PASI) 75 and PASI 90 responses were assessed at baseline and at months 1 and 3 among patients who received TNF-α inhibitors, ustekinumab, IL-17 blockers, and IL-23 blockers. The same responses were also assessed with methotrexate and acitretin for a comparison group. Analyses were performed retrospectively.
Results: The study included 317 patients who received 222 biological and 95 conventional treatments. In the group with BMI of ≥30, the proportion of patients who achieved PASI 75 response was 40.0% (n=26) at month 1 and 55.4% (n=36) at month 3. The proportion of patients who achieved PASI 90 response was 33.8% (n=22) at month 1 and 44.6% (n=29) at month 3 among those receiving biological agents. Improvement was significantly more difficult among obese patients. While the presence of joint involvement affected the success of treatment among obese patients with psoriasis, no relationships were found for smoking, the presence of concomitant psychiatric diseases, or the presence of pruritus in psoriasis.
Conclusion: Biological agents were more successful in achieving PASI 75 and PASI 90 responses in both non-obese and obese individuals. Based on our study, among biological agents, IL-17 and IL-23 inhibitors may be more successful among obese individuals, but neither of them shows superiority over the other.
text/xml
2160-9381
3493
en
Ragıp Ertaş
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
biological agents
Can Biologic Agents Improve Treatment Success in Obese Patients With Psoriasis Vulgaris: A Retrospective Review of 320 Patients With Psoriasis Vulgaris
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2024-01-31
2023-05-01
2024-01-31
2024-02-21
e2024058
Dermatol Pract Concept
Introduction: Obesity plays a major role in the development of many inflammatory disorders including psoriasis.
Objectives: We aimed to demonstrate how treatment responses change according to body mass index among patients with psoriasis.
Methods: In our study, Psoriasis Area and Severity Index (PASI) 75 and PASI 90 responses were assessed at baseline and at months 1 and 3 among patients who received TNF-α inhibitors, ustekinumab, IL-17 blockers, and IL-23 blockers. The same responses were also assessed with methotrexate and acitretin for a comparison group. Analyses were performed retrospectively.
Results: The study included 317 patients who received 222 biological and 95 conventional treatments. In the group with BMI of ≥30, the proportion of patients who achieved PASI 75 response was 40.0% (n=26) at month 1 and 55.4% (n=36) at month 3. The proportion of patients who achieved PASI 90 response was 33.8% (n=22) at month 1 and 44.6% (n=29) at month 3 among those receiving biological agents. Improvement was significantly more difficult among obese patients. While the presence of joint involvement affected the success of treatment among obese patients with psoriasis, no relationships were found for smoking, the presence of concomitant psychiatric diseases, or the presence of pruritus in psoriasis.
Conclusion: Biological agents were more successful in achieving PASI 75 and PASI 90 responses in both non-obese and obese individuals. Based on our study, among biological agents, IL-17 and IL-23 inhibitors may be more successful among obese individuals, but neither of them shows superiority over the other.
Ragıp Ertaş
2024/01/31
10.5826/dpc.1401a58
e2024058
Department of Dermatology, Kayseri City Education and Research Hospital, Kayseri, Turkey 
2160-9381
biological agents
en
e2024058
Scher JU, Ogdie A, Merola JF, Ritchlin C. Preventing psoriatic arthritis: focusing on patients with psoriasis at increased risk of transition. Nat Rev Rheumatol. 2019;15(3):153-166. DOI: 10.1038/s41584-019-0175-0. PMID: 30742092.
Can Biologic Agents Improve Treatment Success in Obese Patients With Psoriasis Vulgaris: A Retrospective Review of 320 Patients With Psoriasis Vulgaris
https://dpcj.org/index.php/dpc/article/download/3493/2426
     Can Biologic Agents Improve Treatment Success
        in Obese Patients With Psoriasis Vulgaris:
         A Retrospective Review of 320 Patients
                 With Psoriasis Vulgaris
                                Atıl Avcı1, Deniz Avcı2, Yılmaz Ulaş1, Ragip Ertaş1


1 Department of Dermatology, Kayseri City Education and Research Hospital, Kayseri, Turkey
2 Department of Internal Medicine, Kayseri City Education and Research Hospital, Kayseri, Turkey



Key words: Psoriasis, obesity, biological agents, body mass index
Citation: Avcı A, Avcı A, Ulaş Y, Etaş R. Can Biologic Agents Improve Treatment Success in Obese Patients With Psoriasis Vulgaris:
A Retrospective Review of 320 Patients With Psoriasis Vulgaris. Dermatol Pract Concept. 2024;14(1):e2024058.
DOI: https://doi.org/10.5826/dpc.1401a58
Accepted: August 29, 2023; Published: January2024
Copyright: ©2024 Avcı et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Atıl Avcı, MD. (Associate professor), Kayseri City Education and Research Hospital, Department of Dermatology
and Allergy- Kayseri, Turkey. Tel: +90 352 315 77 00 Cell Phone: +90 507 240 93 65 E-mail: atilavci@hotmail.com




  ABSTRACT             Introduction: Obesity plays a major role in the development of many inflammatory disorders includ-
                       ing psoriasis.
                       Objectives: We aimed to demonstrate how treatment responses change according to body mass index
                       (BMI) among patients with psoriasis.
                       Methods: In our study, Psoriasis Area and Severity Index (PASI) 75 and PASI 90 responses were as-
                       sessed at baseline and at months 1 and 3 among patients who received TNF-α inhibitors, ustekinumab,
                       IL-17 blockers, and IL-23 blockers. The same responses were also assessed with methotrexate and
                       acitretin for a comparison group. Analyses were performed retrospectively.
                       Results: The study included 317 patients who received 222 biological and 95 conventional treatments.
                       In the group with BMI ≥30, the proportion of patients who achieved PASI 75 response was 40.0%
                       (N = 26) at month 1 and 55.4% (N = 36) at month 3. The proportion of patients who achieved PASI
                       90 response was 33.8% (N = 22) at month 1 and 44.6% (N = 29) at month 3 among those receiving
                       biological agents. Improvement was significantly more difficult among obese patients. The proportion
                       of patients who achieved PASI 75 response was 3.6% at month 1 and 25.0% (N = 7) at month 3




Original Article | Dermatol Pract Concept. 2024;14(1):e2024058                                                                        1
                      among patients receiving conventional systemic treatments. While the presence of joint involvement
                      affected the success of treatment among obese patients with psoriasis, no relationships were found
                      for smoking, the presence of concomitant psychiatric diseases, or the presence of pruritus in psoriasis.
                      Conclusions: Biological agents were more successful in achieving PASI 75 and PASI 90 responses in
                      both non-obese and obese individuals. Based on our study, among biological agents, IL-17 and IL-23
                      inhibitors may be more successful among obese individuals, but neither of them shows superiority
                      over the other.




Introduction                                                         agents (methotrexate and acitretin) in terms of success in
                                                                     achieving PASI 75 and PASI 90 responses based on the pres-
Psoriasis is a chronic, immune-related, systemic inflamma-           ence of joint involvement, smoking habit, concomitant pres-
tory disease that may be accompanied by many comorbid                ence of psychiatric disease, and pruritus.
conditions including psoriatic arthritis, cardiovascular
disorders, cancer, depression, metabolic syndrome, and
obesity [1-5].
                                                                     Methods
    Morphologically, the skin has an erythematous and scaly          This study was conducted in the Chronic Diseases Unit of
appearance in cases of psoriasis; this is due to overstimu-          the Dermatology Department of the Health Sciences Univer-
lation of keratinocytes as well as increased angiogenesis            sity Kayseri Teaching and Research Hospital. Since 2016, all
of dilated blood vessels and infiltration of T lymphocyte-           patients were registered with the PSORTAXIS database [15].
associated immune cells [6,7].                                       The database was updated periodically with data from
    Obesity plays a major role in the development of many            ­follow-up, and photographs at baseline and after treatment
disorders by increasing insulin resistance and fatty acid syn-       were also added to the PSORTAXIS database. Treatments
thesis. It also increases fatty acid release from visceral adipose   were changed based on treatment responses during follow-up.
tissues to organs such as the liver and skeletal muscles [8,9].      Most of the patients are still attending regular follow-up ap-
If nutritional choices remain similar to the current prefer-         pointments. In the course of the present study, the electronic
ences, it is estimated that 38% of the world population will         database was screened for patients with plaque psoriasis and
be overweight with body mass index (BMI) values >25 and              the records of these patients were extracted. Patients receiv-
20% will be obese with BMI >30 in 2030 [8]. Obesity is in-           ing biological agents and conventional agents were included
volved in the etiopathogenesis of many skin disorders includ-        in the research as the study and control groups, respectively.
ing acanthosis nigricans, acne, hyperhidrosis, intertriginous
dermatitis, and acrochordons [10]. In addition, obesity may          Inclusion Criteria
be accompanied by plantar hyperkeratosis, cellulitis, kerato-
                                                                     Patients aged ≤18 years diagnosed with psoriasis vulgaris
sis pilaris, stria distensae, hidradenitis suppurativa, and skin
                                                                     who received any systemic agents (biological agents, metho-
infections [11-13]. Obesity is also an independent risk factor
                                                                     trexate, or acitretin) for therapeutic purposes.
for psoriasis. The increase in the incidence and prevalence
of obesity is almost parallel to clinical exacerbation in the
                                                                     Exclusion Criteria
course of psoriasis [14].
                                                                     Psoriasis patients with a diagnosis other than psoriasis vul-
                                                                     garis (nail psoriasis, pustular psoriasis, erythrodermic pso-

Objectives                                                           riasis, etc); patients aged <18 years; those receiving topical
                                                                     treatment alone; those with small intestine disorders (celiac
In this study, patients with BMI values ≥30 were defined as          disease, enteropathy, etc), pancreas disorders, or hepatobili-
obese while those with BMI <30 were defined as non-obese.            ary disorders that may affect drug levels or BMI; those with
We collected data regarding improvement in the Psoriasis             diseases that may cause lymphatic obstruction (tuberculo-
Area and Severity Index (PASI) 75 and PASI 90 scores of pa-          sis, lymphoma, etc.); those with any malignancies; and those
tients with psoriasis receiving biological agents and conven-        with renal or hepatic failure.
tional treatments. We retrospectively assessed the data and             In this study, TNF-α inhibitors (adalimumab, etaner-
compared the findings according to the patients BMI values.          cept, infliximab, and certolizumab pegol), an IL12/13 in-
In addition, we assessed biological agents and conventional          hibitor (ustekinumab), IL-17 blockers (secukinumab and




2                                                                        Original Article | Dermatol Pract Concept. 2024;14(1):e2024058
ixekizumab), and IL-23 blockers (risankizumab and gusel-              agents, the highest mean age was found for ixekizumab while
kumab) were assessed as biological agents. In addition,               the lowest mean age was found for guselkumab (Table 2).
methotrexate and acitretin were assessed as systemic con-                There were 127 men (57%) and 95 women (43%) in
ventional agents.                                                     the group treated with biological agents while there were
    BMI was calculated for all patients using the following           63 men and 32 women in the group treated with conven-
formula: BMI = weight (kg)/height2 (m2). The patients were            tional agents, indicating no significant difference in genders
                                        2
classified as obese (BMI ≥30 mg/m ) and non-obese (BMI                between the groups (P = 0.310).
<30 mg/m2; normal and overweight). PASI 75 and PASI 90                   The mean BMI was 28.2±5.3 kg/m2 in the group treated
responses were assessed at baseline and at months 1 and 3,            with biological agents and 27.6±5.9 kg/m2 in the group
and percentage changes were recorded for the PASI scores.             treated with conventional agents. The groups were compa-
The achievement of PASI 75 or PASI 90 response was consid-            rable regarding BMI (P = 0.360). Furthermore, there was no
ered as the criterion of success for each individual agent used.      significant difference in BMI between patients treated with
    Approval for this study was obtained from the Ethics              different conventional agents (P = 0.264).
Committee of Kayseri City Education and Research Hospital                Among these patients with psoriasis vulgaris, the mean
(21.02.2023/800).                                                     disease duration was 17.7±10.5 years for patients treated
                                                                      with biological agents while it was 10.1±7.9 years for pa-
Statistical Analysis                                                  tients treated with conventional agents, and the difference
The normal distribution of the data was tested using the              was significant (P < 0.001). The mean disease duration was
­Shapiro-Wilk test and histograms. Data with normal dis-              15.4±10.4 years for the entire study population.
tribution are presented as mean ± standard deviation while               Of the patients treated with biological agents, 65.3%
data with skewed distribution are presented as m
                                               ­ edian                (N = 145) were biological-naive patients at baseline while
(min-max). Categorical data were analyzed using the ­chi-             34.7% (N = 77) had switched from a different biologi-
square test and Fisher exact test. Continuous data with               cal agent. The most commonly used biological agent after
­normal distribution were analyzed using Student t-test while         switching was secukinumab (52.5%; N = 31) (Table 3).
nonparametric data with skewed distribution were analyzed
using the Mann-Whitney U test. All data analyses were per-            Patients with BMI <30
formed using IBM SPSS Statistics 23.0 (IBM Corp.).                    Among the patients who had achieved PASI 75 at month
                                                                      1, the highest rate was observed with ixekizumab (81.8%;

Results                                                               N = 9) while the lowest rate was observed with etanercept
                                                                      (12.5%; N = 1) (Table 4).
This study included 317 patients who received 222 biologi-               The proportion of patients who achieved PASI 75 re-
cal and 95 conventional treatments. The mean age was 45.2             sponse was 13.4% at month 1 and 29.90% (N = 20) at
years in the entire study population, while it was 47.6±12.1          month 3 among patients treated with conventional agents
years among patients treated with biological agents and               (Table 5).
46.1±12.2 years among patients treated with conventional                 Among those treated with biological agents, the propor-
agents, with no significant difference between these groups           tion of patients who achieved PASI 75 response was 49.0%
(P = 0.075) (Table 1). In the group treated with biological           (N = 77) at month 1 and 70.1% (N = 110) at month 3, while



    Table 1. Characteristics of patients receiving biologic agents and conventional systemic therapy.
                                                                      Conventional
   Continuous Variables            Biologics (All) (N = 222)       treatment (N = 103)       MTX (N = 57)      Acitretin (N = 46)
 Age (years)/mean±SD                        46.14±12.16               42.99±13.88            41.65±13.34           44.65±14.51
 Body mass index mean±SD                    28.15±5.31                 27.09±6.05             27.35±6.04           26.75±6.12
 PASI improvement during                66.67(-150-100)               40.00(0-100)           33.33(0-100)          50.00(0-100)
 the first month
 PASI improvement during                100±(-150-100)                50.00(0-100)           50.00(0-100)          50.00(0-100)
 the third month
 Duration of the disease                    17.68±10.54                 9.74±7.77             10.42±7.29            8.89±8.33
 (years), mean ±SD

MTX = methotrexate; PASI = Psoriasis Area and Severity Index; SD = standard deviation.




Original Article | Dermatol Pract Concept. 2024;14(1):e2024058                                                                    3
4
                                                                        Table 2. Age, body mass index, duration of disease and Psoriasis Area and Severity Index improvements in patients receiving biologic agents.
                                                                    Continuous         ADALIMUMAB           ETANERCEPT           INFLIXIMAB      SERTOLIZUMAB     USTEKINUMAB       SECUKINUMAB      IXEKIZUMAB RISANKIZUMAB GUSELKUMAB
                                                                     Variables           (N = 39)             (N = 10)             (N = 14)      PEGOL (N = 10)      (N = 56)          (N = 59)         (N= 16)     (N = 10)    (N = 8)
                                                                  Age (years)            49.69±12.49         45.90±11.86         48.07±10.35      43.00±16.50      47.91±10.83       47.47±10.30     49.00±9.64      46.50±6.98      41.63±8.78
                                                                  mean ±SD
                                                                  Body mass               27.46±4.89         27.19±3.19          28.07±6.27        29.84±6.14       28.74±6.24       27.64±4.34      30.03±6.46      27.41±4.90      26.26±3.94
                                                                  index mean ±SD
                                                                  PASI                75.00 (-100-100)       50.00(0-75)      55.00 (-150-100)   61.90 (25-100)   66.67 (-50-100)   71.43 (0-100)        83.97      30.95 (0-100)    50 (25-100)
                                                                  improvement                                                                                                                          (33-100)
                                                                  during the first
                                                                  month
                                                                  PASI                 100 (-100-100)       66.67 (0-100) 56.25 (-150-100)       72.50 (25-100)   100 (-100-100)    100 (-100-100)   100 (33-100)   60.71 (0-100)   70.83 (50-100)
                                                                  improvement
                                                                  during the third
                                                                  month
                                                                  Duration of the        20.85±13.94         18.40±8.89          16.21±8.88       17.00±10.72      16.88±10.13       18.97±10.32     14.81±6.94      12.60±6.62      13.00±6.67
                                                                  disease (years)
                                                                  mean ±SD

                                                                 PASI = Psoriasis Area and Severity Index; SD = standard deviation.




Original Article | Dermatol Pract Concept. 2024;14(1):e2024058
  Table 3. The percentages of patients are shown according to obesity, smoking, psychiatric disease,
        joint involvement and pruritus (percentages related to the switching of drugs are also
                                         shown in the table).
                                                                                PHSYCHIATRIC    JOINT
                              OBESITY            SWITCH           SMOKING         DISEASE    INVOLVEMENT                PRURITIS
 TOTAL                          28.6%            23.7%              53.6%        16.7% (N=37)       31.9% (N=71)          77.0%
 (BIOLOGIC)                     (N=65)           (N=77)            (N=119)                                               (N=171)
 ADALIMUMAB                     25.6%         17.9% (N=7)           53.8%        15.4% (N=6)        34.2% (N=13)         74.4%
                                (N=10)                              (N=21)                                               (N=29)
 ETANERCEPT                 20.0% (N=2)       20.0% (N=2)        50.0% (N=5)      0.0% (N=0)        44.4% (N=4)          70.0%
                                                                                                                         (N=7)
 INFLIXIMAB                 28.6% (N=4)       21.4% (N=3)        57.1% (N=8)     21.4% (N=3)        42.9% (N=6)          92.9%
                                                                                                                         (N=13)
 SERTOLIZUMAB               40.0% (N=4)       40.0% (N=4)        40.0% (N=4)     10.0% (N=1)        57.1% (N=4)          70.0%
                                                                                                                         (N=7)
 USTEKINUMAB                    30.4%            17.9%              64.3%        14.3% (N=8)        26.5% (N=13)         73.2%
                                (N=17)           (N=10)             (N=36)                                               (N=41)
 SECUKINUMAB                    32.2%            52.5%              47.5%        23.7% (N=14)       38.0% (N=19)         78.0%
                                (N=19)           (N=31)             (N=28)                                               (N=46)
 IXEKIZUMAB                 31.3% (N=5)       50.0% (N=8)        50.0% (N=8)      6.3% (N=1)        28.6% (N=4)          81.3%
                                                                                                                         (N=13)
 RISANKIZUMAB               20.0% (N=2)       60.0% (N=4)        40.0% (N=4)     10.0% (N=1)        40.0% (N=4)          90.0%
                                                                                                                         (N=9)
 GUSELKUMAB                 25.0% (N=2)       75.0% (N=6)        62.5% (N=5)     37.5% (N=3)        57.1% (N=4)          75.0%
                                                                                                                         (N=6)
 TOTAL                          27.2%            -----------      54.4% (N=)     22.3% (N=23)       17.4% (N=18)          81.5%
 (CONVENTIONAL)                 (N=28)                                                                                   (N=103)
 METHOTREXATE                   31.6%            -----------        54.4%        21.1% (N=12)       17.5% (N=10)         82.5%
                                (N=18)                              (N=31)                                               (N=47)
 ACITRETIN                 21.7% (N=10)          -----------     58.7% (N=27) 23.9% (N=11)          17.4% (N=8) 80.4% (N=37)




the proportion of patients who achieved PASI 90 response              at month 3 among patients treated with biological agents
was 33.8% (N = 53) at month 1 and 58.6% (N = 92) at                   (Table 5). The highest rate was observed with ixekizumab
month 3 (Table 5).                                                    (42.1%; N = 8) (Table 6). In the group treated with conven-
    In the group treated with conventional systemic agents,           tional systemic agents, no patient achieved PASI 90 response
the proportion of patients who achieved PASI 90 response              at month 1, while the proportion of patients who achieved
was 9.0% (N = 6) at month 1, and this figure increased to             PASI 90 response at month 3 was 3.6% (N = 1) (Table 5).
23.9% (N = 16) at month 3.                                               In summary, when the entire study population was con-
                                                                      sidered, BMI was ≥30 kg/m2 for 224 patients and <30 kg/
Patients with BMI ≥30                                                 m2 for 93 patients. The PASI assessments changed as seen
The proportion of patients who achieved PASI 75 response              in Table 7 when the entire study population was not classi-
was 40.0% (N = 26) at month 1 and 55.4% (N = 36) at                   fied into treatment groups. At month 3, PASI scores showed
month 3 among patients treated with biological agents.                improvement in 48.2% (N = 108) of the non-obese patients
The highest rate was observed with ixekizumab (60.0%;                 and 32.3% (N = 30) of the obese patients. The rate of im-
N = 3) while the lowest rate was observed with etanercept             provement was significantly worse among obese patients
(0%; N = 0).                                                          (P = 0.009). Although a difference could be observed at
    The proportion of patients who achieved PASI 75 re-               month 1, it was not reflected at the same extent in our entire
sponse was 3.6% at month 1 and 25.0% (N = 7) at month 3               study population (P = 0.063). For PASI 75 response, there
among patients treated with conventional agents.                      was improvement in favor of non-obese patients at months
    The proportion of patients who achieved PASI 90 re-               1 and 3, but these differences did not reach statistical signif-
sponse was 33.8% (N = 22) at month 1 and 44.6% (N = 29)               icance (P = 0.124 and P = 0.673, respectively).



Original Article | Dermatol Pract Concept. 2024;14(1):e2024058                                                                      5
6
                                                                     Table 4. PASI 75 and PASI 90 responses during the first and third months in patients with a body mass index <30 (normal and overweight) when
                                                                                                                         the biologics were evaluated separately.
                                                                  Continuous ADALIMUMAB ETANERCEPT INFLIXIMAB SERTOLIZUMAB USTEKINUMAB SECUKINUMAB IXEKIZUMAB RISANKIZUMAB GUSELKUMAB Total biologic
                                                                   Variables    (N=29)     (N=8)     (N=10)    PEGOL (N=6)    (N=39)      (N=39)      (N=12)      (N=8)       (N=6)      (N=157)
                                                                  Patients who     48.3% (N=14)              12.5%   50% (N=5)   33.3% (N=2)   53.8% (N=21)   52.5% (N=21)   81.8% (N=9)   25% (N=2)     33.3% (N=2)   49.0%
                                                                  achieved                                   (N=1)                                                                                                     (N=77)
                                                                  PASI 75
                                                                  during the
                                                                  first month
                                                                  Patients who     69.0% (N=20)              37.7%    40.0%      50.0% (N=3)   76.9% (N=30)   84.5% (N=33)      100%       50.0% (N=4)   33.3% (N=2)    70.1%
                                                                  achieved                                   (N=3)    (N=4)                                                    (N=11)                                  (N=110)
                                                                  PASI 75 the
                                                                  third month
                                                                  Patients who      31.0% (N=9)        0.0% (N=0)     50.0%      0.0% (N=0)    48.7% (N=19)   33.3% (N=13)   45.5% (N=5)   12.5% (N=1)   16.7% (N=1)   33.8%
                                                                  achieved                                            (N=5)                                                                                            (N=53)
                                                                  PASI 90 the
                                                                  first month
                                                                  Patients who     58.6% (N=17)              12.5%    30.0%      33.3% (N=2)   69.2% (N=27)   67.5% (N=27)      100%       37.5% (N=3)   16.7% (N=1)   58.6%
                                                                  achieved                                   (N=1)    (N=3)                                                    (N=11)                                  (N=92)
                                                                  PASI 75 the
                                                                  third month

                                                                 PASI = Psoriasis Area and Severity Index.




Original Article | Dermatol Pract Concept. 2024;14(1):e2024058
    Table 5. Patients were classified into two groups as those treated with biological agents and
conventional agents. No significant difference was observed in the achieving of PASI 75 and PASI 90
                             responses during the first and third months
                                                BIOLOGICAL                                         CONVENTIONAL
                                  BMI <30                BMI >30                         BMI <30           BMI >30
                                  (N=157)                 (N=65)           P             (N=67)             (N=28)            P
 PASI 75 during the            49.0% (N=77)           40.0% (N=26)       0.239      13.4% (N=9)          3.6% (N=1)        0.272
 first month
 PASI 90 during the            33.8% (N=53)           33.8% (N=22)       1.000       9.0% (N=6)          0.0% (N=0)        0.175
 first month
 PASI 75 during the           70.1% (N=110)           55.4% (N=36)       0.044      29.9% (N=20)         25.0% (N=7)       0.804
 third month
 PASI 90 during the            58.6% (N=92)           44.6% (N=29)       0.075      23.9% (N=16)         3.6% (N=1)        0.014
 third month

BMI = body mass index; PASI = Psoriasis Area and Severity Index.




    When patients were classified into two groups as those           90 at month 1; P = 0.64 for PASI 75 at month 3, P =0.110
treated with biological agents and conventional agents, no           for PASI 90 at month 3). At month 3, the rates of achieving
significant difference was observed in achieving PASI 75 and         PASI 75 and PASI 90 responses were better among patients
PASI 90 responses at months 1 and 3 (Table 5). At month 3,           without pruritus.
the proportion of patients who achieved PASI 75 response
was 70.1% (N = 110) among non-obese patients and 44.6%               Psychiatric Disorders
(N=29) among obese patients treated with biological agents,          There was a concomitant psychiatric disorder among 16.7%
reflecting a significant difference (p=0.044). A similar trend       (N = 37) of the patients treated with biological agents and
was observed for PASI 90 achievement at month 3 in favor             22.3% (N = 23) of the patients treated with conventional
of non-obese patients (p=0.075). Among patients treated              agents (P = 0.121).
with conventional agents, the difference was statistically sig-
nificant (P = 0.014).
                                                                     Smoking
                                                                     There was no significant correlation between smoking and
Joint Involvement                                                    the achievement of PASI 75 and PASI 90 responses at months
It is apparent that joint involvement is a good predictor for        1 or 3 (P = 0.420 for PASI 75 at month 1, P = 0.322 for PASI
achievement of PASI 75 and PASI 90 responses (P = 0.007              90 at month 1; P = 0.670 for PASI 75 at month 3, P =0 .591
for PASI 75 at month 1, P = 0.044 for PASI 90 at month 1;            for PASI 90 at month 3).
P = 0.003 for PASI 75 at month 3; P = 0.011 for PASI 90 at
month 3).
    Joint involvement was more common among older pa-                Conclusions
tients. The mean age was 49.2±10.2 years among patients
                                                                     Psoriasis develops when an interaction occurs between ke-
with joint involvement and it was 45.6±11.9 years among
                                                                     ratinocytes and immune cells. It may be induced by damage
those without joint involvement (P = 0.013).
                                                                     to the keratinocytes due to congenital immune system acti-
    Disease duration showed no significant difference re-
                                                                     vation or neutrophil activation due to infection, increased
garding joint involvement. The mean disease duration was
                                                                     angiogenesis, and dendritic cell activation [16]. The IL-23
15.8±9.4 years among patients with joint involvement and
                                                                     released from dendritic cells converts T cells into Th-17 cells
14.5±10.8 years among those without joint involvement
                                                                     to produce IL-17 and IL-22. As a result, psoriatic plaque
(P = 0.366).
                                                                     formation starts due to keratinocyte hyperproliferation and
                                                                     differentiation. In brief, the IL-23/Th17 axis plays a pivotal
Pruritus                                                             role in the pathogenesis of psoriasis [16-18].
There was no significant correlation between pruritus and               Obesity is considered an independent risk factor for pso-
achievement of PASI 75 and PASI 90 responses at months 1             riasis, increasing the risk of psoriasis development. It has
and 3 (P = 0.338 for PASI 75 at month 1, P = 0.502 for PASI          been reported that each 1 kg/m2 increase in BMI corresponds



Original Article | Dermatol Pract Concept. 2024;14(1):e2024058                                                                     7
8
                                                                                 Table 6. PASI 75 and PASI 90 responses during the first and third months in patients with a BMI >30 (obese) when the biologics
                                                                                                                                   were evaluated separately.
                                                                  Continuous ADALIMUMAB ETANERCEPT INFLIXIMAB SERTOLIZUMAB USTEKINUMAB SECUKINUMAB IXEKIZUMAB RISANKIZUMAB GUSELKUMAB Total biologic
                                                                   variables    (N=10)     (N=2)      (N=4)    PEGOL (N=4)    (N=17)      (N=19)      (N=5)       (N=2)       (N=2)      (N=65)
                                                                 Patients who      60.0% (N=6)        0.0% (N=0)   25.0% (N=1)   50.0% (N=2)   35.3% (N=6)   42.1% (N=8)    60.0% (N=3)   0.0% (N=0)    0.0% (N=0)   40.0% (N=26)
                                                                 achieved
                                                                 PASI 75 the
                                                                 first month
                                                                 Patients who      80.0% (N=8)        100% (N=2) 25.0% (N=1)     50.0% (N=2)   47.1% (N=8)   52.6% (N=10)   60.0% (N=3)   0.0% (N=0)   100.0% (N=2) 55.4% (N=36)
                                                                 achieved
                                                                 PASI 75 the
                                                                 third month
                                                                 Patients who      60.0% (N=6)        0.0% (N=0)   25.0% (N=1)   25.0% (N=1)   23.5% (N=4)   42.1% (N=8)    40.0% (N=2)   0.0% (N=0)    0.0% (N=0)   33.8% (N=22)
                                                                 achieved
                                                                 PASI 90 the
                                                                 first month
                                                                 Patients who      70.0% (N=7)        0.0% (N=0)   25.0% (N=1)   50.0% (N=2)   35.3% (N=6)   47.4% (N=9)    60.0% (N=3)   0.0% (N=0)   50.0% (N=1)   44.6% (N=29)
                                                                 achieved
                                                                 PASI 75 the
                                                                 third month

                                                                 PASI = Psoriasis Area and Severity Index.




Original Article | Dermatol Pract Concept. 2024;14(1):e2024058
   Table 7. The PASI assessments changed as                        month 3. Etanercept (10%; N = 1/10) and infliximab
 shown below when the entire study population                      (35.7%; N = 5/14) seemed to be the weakest agents regard-
 was not classified into treatment groups during                   ing achievement of PASI 75 response at months 1 and 3.
           the first and third months.                                Regarding PASI 90 response, there was no significant
                                                                   difference among biological agents at month 1. However,
                      BMI <30             BMI >30
                                                                   ixekizumab seemed more successful at month 3 (87.5%;
                      (N=224)              (N=93)             P
                                                                   N = 14/16). Only one patient achieved PASI 90 response at
 PASI 75 the      38.4% (N=86)        29.0% (N=27)         0.124
 first month                                                       month 3 with etanercept.

 PASI 90 the      58.0% (N=130) 46.2% (N=43)               0.063      When the rates of PASI 90 response were considered,
 first month                                                       no significant difference was observed among biological
 PASI 75 the      26.3% (N=59)        23.7% (N=22)         0.673   agents at moth 1, while ixekizumab seemed better at month
 third month                                                       3 (87.5% (N = 14/16). At month 3, etanercept seemed to be
 PASI 90 the      48.2% (N=108) 32.3% (N=30)               0.009   the weakest agent regarding PASI 90 response as only one
 third month                                                       patient in this subgroup achieved PASI 90.
                                                                      A recent meta-analysis supports the findings of the pres-
BMI = body mass index; PASI = Psoriasis Area and Severity Index.
                                                                   ent study [26]. According to that meta-analysis, infliximab,
                                                                   ixekizumab, brodalumab, secukinumab, risankizumab, and
to an approximately 4% increase in the risk of psoriasis de-       guselkumab were superior to ustekinumab and three other
velopment [19,20]. In systematic reviews, it was emphasized        TNF-α inhibitors (adalimumab, certolizumab, and etaner-
that excessively high BMI values are positively associated         cept) in terms of PASI 90 response rates. Ustekinumab and
with disease severity in cases of psoriasis [18,21].               adalimumab were also superior to etanercept. These findings
    Unlike other adipokines, the adiponectin level decreases       are in agreement with our study. In another meta-analysis,
in the presence of obesity. A similar decrease is also seen in     it was suggested that IL-17, IL-12/23, and IL-23 inhibitors
patients with psoriasis [22-24].                                   have comparable efficacy profiles in terms of PASI 75 and
    At months 1 and 3, patients treated with biological            PASI 100 response rates and that these agents are superior to
agents (N = 222) had superior results compared to patients         TNF-α inhibitors [27].
treated with conventional agents (N = 95; methotrexate                Guselkumab was the most commonly used agent after
and acitretin) in terms of achieving PASI 75 and PASI 90           switching treatments (75%; N = 6); however, the number
responses in both groups of patients with BMI ≥30 kg/m2            of patients who received secukinumab after switching was
and <30 kg/m2 in the present study. This adversely affected        highest (N = 31) (Table 3). Adalimumab and etanercept
                                                          2
treatment success in the group with BMI ≥30 kg/m . Simi-           (TNF-α inhibitors) were the most commonly changed bio-
larly, previous studies found that high BMI values increase        logical agents.
disease activity and make it difficult to respond to biological       In our study, it was seen that smoking habit was not a
treatment agents [1, 3].                                           significant parameter in terms of achieving PASI 75 or PASI
    IL-17 inhibitors (ixekizumab and secukinumab) and              90 responses in the groups of patients with BMI of <30 and
IL-23 inhibitors (risankizumab and guselkumab) may be              BMI of ≥30 in comparisons among biological agents or when
better alternatives for obese individuals compared to other        biological agents were compared with systemic conventional
biological and systemic conventional treatments (metho-            agents. Based on a meta-analysis, it is known that smoking
trexate and acitretin). These agents have higher treatment         facilitates drug-induced psoriasis development in patients
success and fewer adverse effects compared to systemic con-        with inflammatory bowel disease, and it was also reported
ventional treatments; they can facilitate the achievement of       that obesity further increases the risk of drug-induced pso-
PASI 75 and PASI 90 responses more readily. In a study by          riasis [28,29].
Anghel et al., it was observed that obese patients responded          The rate of concomitant psychiatric disorders was higher
more poorly to TNF-α inhibitors and IL-12/23 inhibitors            in the group treated with biological agents (16.7%; N = 37)
compared to IL-17 and IL-23 inhibitors [6]. In our study, we       compared to the group treated with systemic conventional
assessed risankizumab and guselkumab, which were recently          agents (22.3%; N = 23) (P = 0.121). Based on this finding,
introduced in the treatment of psoriasis. These agents may be      it can be suggested that higher rates of treatment success
better therapeutic alternatives for obese patients.                and better profiles of adverse effects with the use of biolog-
    In our study, ixekizumab achieved the best and fastest         ical agents compared to systemic conventional agents may
rates of PASI 75 response at months 1 and 3 compared               have improved the psychological status of the patients. In a
to other biological agents. The PASI 75 response rate was          study of 91 patients in which the risk of psychiatric illness
75% (N = 12/16) at month 1 and 87.5% (N = 14/16) at                and suicide was investigated, it was reported that the risk of



Original Article | Dermatol Pract Concept. 2024;14(1):e2024058                                                                 9
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Original Article | Dermatol Pract Concept. 2024;14(1):e2024058                                                                            11
