Clinical Reviews in Allergy & Immunology

, Volume 44, Issue 2, pp 121–140 | Cite as

Biologic Therapies in the Treatment of Psoriasis: A Comprehensive Evidence-Based Basic Science and Clinical Review and a Practical Guide to Tuberculosis Monitoring

  • Raja K. Sivamani
  • Heidi Goodarzi
  • Miki Shirakawa Garcia
  • Siba P. Raychaudhuri
  • Lisa N. Wehrli
  • Yoko Ono
  • Emanual MaverakisEmail author


The treatment of psoriasis has undergone a revolution with the advent of biologic therapies including infliximab, etanercept, adalimumab, efalizumab, golimumab, certolizumab, alefacept, secukinumab, abatacept, and ustekinumab. These medications are designed to target specific components of the immune system and are a major technological advancement over traditional immunosuppressive medications. Herein, we present a comprehensive, unbiased comparison of these medications focusing on their differences. For example, TNF antagonists can differ in the way they are dissolved and administered, the effector molecules they can bind, serum peak and trough levels, the types of intracellular signals they can induce, the in vivo complexes that they can form, their protein structure, and their incidence and timing of rare adverse events, among other things. A critical review of the clinical studies that have tested the efficacy of these molecules is also presented including head-to-head comparison trials. The safety of biologics in terms of their long-term adverse events is discussed, as is their use in different types of psoriasis and in different patient populations. Finally, all anti-TNF agents have been associated with a variety of serious and “routine” opportunistic infections, particularly tuberculosis. For this reason, anti-tuberculosis testing both prior to the initiation of a biologic therapy and annually during treatment is pertinent. The uses and limitations of both the tuberculin skin test (TST) and QuantiFeron®-TB Gold (QFT) are discussed, as is the care of patients who present with latent tuberculosis infection prior to the initiation of biologic therapy. Recommendations for tuberculosis monitoring are provided.


Psoriasis Biologics Quantiferon Tuberculosis TNF Ustekinumab Adalimumab Etanercept Infliximab Golimumab Certolizumab Abatacept Briakinumab Alfecept Efalizumab Secukinumab 



EM holds career awards from the Burroughs Wellcome Fund and the Howard Hughes Medical Institute. The authors would like to thank Stephanie Chu for help with design and creation of figures and Ern Loh for providing the clinical photo.


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Copyright information

© Springer Science+Business Media, LLC (outside the USA) 2012

Authors and Affiliations

  • Raja K. Sivamani
    • 1
  • Heidi Goodarzi
    • 1
  • Miki Shirakawa Garcia
    • 1
  • Siba P. Raychaudhuri
    • 2
  • Lisa N. Wehrli
    • 1
    • 2
  • Yoko Ono
    • 1
    • 2
  • Emanual Maverakis
    • 1
    • 2
    Email author
  1. 1.Department of Dermatology, School of MedicineUniversity of California, DavisSacramentoUSA
  2. 2.Veterans Affairs Northern California Health Care SystemSacramentoUSA

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