Psoriasis is a chronic disease. In general, patients with moderate-to-severe psoriasis have remissions and relapses. In particular, the chronicity of the disease has a major impact on the patient. The availablity of biologics have revolutionized the therapeutic approach from rotational therapy to long-term maintenance. Such is of major significance for patients, who now can live without the continuous fear for relapses.
The question arises whether continuous maintenance treatment is needed in those patients who have perfect disease control. Is true disease modification possible and if so in which patients and after what time of successful maintenance treatment?
From clinical trials we know that discontinuation of treatment after 6 months or even after a few years results in a relapse in virtually all patients. Dermatologists are therefore reluctant to discontinue treatment. Discontinuation of treatment may also run a risk of inducing immunogenicity and loss of biologic efficacy. Long-term maintenance treatment with biologics has become the general standard way biologics are used for psoriasis patients.
What should be done if, after 5 years or 10 years of continuous treatment, patients remain completely clear from psoriatic lesions? The patients are afraid for relapses. They do not want to return to the discomfort of rotational therapies with remissions and exacerbations. As dermatologist we have no clues to predict whether the patient will remain in remission or not. Furthermore, there is some thought that the continuation of the biologic, even in a patient free from psoriatic lesions, may be helpful to prevent psoriasis comorbidities, including cardiovascular disease, albeit strong evidence that such continued treatment with biologics prevents comorbidity is not available so far.
At present no treatment algorithms are available for long-term treatment with biologics other than continuous treatment. At present it is ‘trial and error’ to find out whether psoriasis relapses following discontinuation of a biologic in a patient who is clear for some time. From real clinical practice studies we need the evidence for planning dose reduction or discontinuation.
Guidelines should guide long-term treatment for those patients who are in remission for some time. Sadly, evidence is lacking to support such guidelines. To what extent may biologics cause true disease modification? Studies in real clinical practise are needed to develop treatment paradigmas for the future.