John Koo, MD, discusses highlights from his lecture Systemic Medications in Psoriasis on Friday, November 4, 2022, at the PA/NP Elevate-Derm Conference in Tucson, Arizona.

In this video

In conversation with Veronica Richardson, MSN, CRNP, Dr. Koo makes the case that older oral agents shouldn't be left on the shelf just because biologics arrived. He highlights acitretin (Soriatane) as a vitamin A retinoid that appeals to patients because it's never been labeled an immunosuppressant and actually carries an anti-cancer effect—useful especially in elderly patients at low, well-tolerated doses of 25 mg/day or less. He also pushes back on the fear surrounding cyclosporine, noting clinicians conflate transplant use with short-term dermatology use in healthier patients; at 5 mg/kg/day he finds it works better than any biologic for getting patients under control before transitioning to another agent, with kidney risk kept in check by not letting creatinine rise more than 30% above baseline.

Dr. Koo calls apremilast (Otezla) a game changer because it's the only internal medication usable for any amount of psoriasis—even two plaques on an elbow—for patients who simply can't make topicals work. Finally, he frames deucravacitinib (Sotyktu) as an unusual, first-of-its-kind agent with no black box warning, minimal side effects, and efficacy he estimates at roughly twice that of apremilast, requiring only tuberculosis testing before starting and periodic triglyceride monitoring.

  • Acitretin (Soriatane) is a retinoid patients accept as a "vitamin" rather than an immunosuppressant, has an anti-cancer effect, and is well tolerated long-term at 25 mg/day or less—particularly in elderly patients.
  • Cyclosporine dermatology use differs from transplant use: short-term, in healthier patients, with no convincing dermatology evidence of increased cancer risk beyond non-melanoma skin cancer in very fair skin; at 5 mg/kg/day it can outperform biologics as a bridge, with kidney safety maintained by keeping creatinine under 30% above baseline.
  • Apremilast (Otezla) is the only internal medication that can be used for any amount of psoriasis, making it valuable when patients can't sustain topical therapy.
  • Deucravacitinib (Sotyktu) is unlike other JAK inhibitors—approved for psoriasis with no black box warning, minimal side effects, and possibly about twice the efficacy of apremilast.
  • Deucravacitinib requires only tuberculosis testing before starting and periodic triglyceride monitoring for small, asymptomatic increases.