Table 1.

Biologic therapy algorithm for selecting a psoriasis treatment in individuals with comorbidities or in special populations, based on a review of the current literature

Biologic therapy	Psoriatic arthritis	Multiple sclerosis	Congestive heart failure	Inflammatory bowel diseasea	Hepatitis B	Latent tuberculosisb	Pediatric psoriasis	Childbearing and nursing potentialc	NMSC and lymphoma	COVID-19
TNF inhibitors
Adalimumab	First line	Avoid	Avoidd	First line (CD and UC)	Third line	Second line	Fourth line (EU: age > 4)	Third line	Third line (NMSC) Avoid (lymphoma)	Second line
Etanercept	First line	Avoid	Avoidd	Fourth line	Third line	Second line	Third line (age > 4)	Third line	Third line (NMSC) Avoid (lymphoma)	Second line
Infliximab	First line	Avoid	Avoidd	First line (CD and UC)	Third line	Second line	NA	Third line	Third line (NMSC) Avoid (lymphoma)	Second line
Certolizumab pegol	First line	Avoid	Avoidd	Second line (CD)	Third line	Second line	NA	First line	Third line (NMSC) Avoid (lymphoma)	Second line
IL-17 inhibitors
Ixekizumab	First line	First line	First line	Avoid	First line	First line	Second line (age > 6)	Fourth line	Second line	Third line
Secukinumab	First line	First line	First line	Avoid	First line	First line	NA	Second line	Second line	Third line
Brodalumab	NA	First line	First line	Avoid	First line	First line	NA	Fourth line	Second line	Third line
IL-12/23 inhibitors
Ustekinumab	Third line	Second line	First line	Second line (CD)	Third line	Second line	First line (age > 6)	Second line	First line	First line
IL-23 inhibitors
Guselkumab	Second line	Third line	First line	Third line	Second line	First line	NA	Fourth line	Second line	First line
Tildrakizumab	NA	Third line	First line	Third line	Second line	First line	NA	Fourth line	Second line	First line
Risankizumab	NA	Third line	First line	Third line	Second line	First line	NA	Fourth line	Second line	First line

CD Crohn’s disease, COVID-19 coronavirus disease 2019, EU Europe, IL interleukin, LTBI latent tuberculosis infection, NA not applicable, NMSC nonmelanoma skin cancer, NYHA New York Heart Association, TNF tumor necrosis factor, UC ulcerative colitis

^aIncludes CD and UC

^bDetermine LTBI status: if positive, initiate antituberculosis prophylaxis at least 1–2 months prior to biologic therapy

^cThe authors of this article do not fully agree with #2–4 of the treatment algorithm

^dContraindicated in NYHA class 3 and 4. Attain baseline echocardiogram in NYHA class 1 and 2. Avoid in patients with ejection fraction < 50%