New French Psoriasis Guidelines Add Biologics, Comorbidity Guidance to Algorithm

For the first time in 6 years, clinicians managing adults with moderate to severe psoriasis have a new French treatment roadmap—one that elevates certain biologics to first-line status alongside methotrexate and addresses a broader range of comorbid conditions than its predecessor.

Why Updated Guidelines Were Needed: New Drug Classes, Evolving Evidence

The prior French guidelines for systemic psoriasis treatment dated to 2019, before inhibitors of the p19 subunit of interleukin-23 (IL-23) and the tyrosine kinase 2 (TYK2) inhibitor deucravacitinib became available. The Psoriasis Research Group of the French Society of Dermatology convened a 22-member multidisciplinary working group comprising dermatologists, rheumatologists, immunologists, and general practitioners to develop updated decision-making algorithms.

Published in Journal of the European Academy of Dermatology and Venereology, the 2025 guidelines incorporated a MEDLINE literature review covering January 2017 through December 2023, supplemented by systematic reviews of meta-analyses through January 2025. A 27-member external review panel—including 2 people with psoriasis—scored each recommendation on a 1-to-9 scale; only recommendations on which at least 80% of reviewers scored a 7 or higher were retained.

First-Line Treatment Algorithm: Biologics Gain Ground Alongside Methotrexate

The working group’s most consequential shift from 2019 involved first-line treatment for people with psoriasis who have no symptomatic comorbidities. The group proposed methotrexate, adalimumab, or ustekinumab as equivalent first-line systemic options, reasoning that biosimilar availability for the older biologics had substantially reduced cost barriers. The authors stated that "reimbursed first-line access for psoriasis-specific drugs is desirable," citing favorable benefit-to-risk profiles for these agents.

For people with very severe disease—defined as body surface area greater than 50% combined with high disease burden—the working group suggested IL-17 inhibitors, IL-23 inhibitors, or infliximab as first-line options.

Efficacy and Drug Survival Data Highlight Variation Across Biologic Classes

Efficacy data drawn from a Cochrane network meta-analysis revealed substantial differences among approved agents. Bimekizumab demonstrated the highest short-term efficacy, with 86% of patients achieving Psoriasis Area Severity Index score of 90 at week 24 compared with 72% each for ixekizumab and risankizumab, 69% for secukinumab, 67% for guselkumab, 51% for ustekinumab, 48% for adalimumab, 32% for deucravacitinib, and 12% for apremilast. One-year drug survival ranged from 82% for risankizumab to 49% for etanercept.

Comorbidity-Specific Guidance: Cardiovascular Risk, IBD, and Pregnancy

The 2025 update devoted substantial attention to tailoring treatment to comorbid conditions. For people with psoriasis and high or very high cardiovascular risk, the working group recommended methotrexate or tumor necrosis factor (TNF) inhibitors as preferred first-line choices while recommending against ciclosporin or acitretin. Those with advanced heart failure (New York Heart Association class III/IV) were advised against TNF inhibitors and ciclosporin; methotrexate, IL-12/23 inhibitors, IL-17 inhibitors, IL-23 inhibitors, or apremilast were suggested instead.

For people with psoriasis and inflammatory bowel disease requiring treatment for both conditions, the working group recommended first-line use of targeted therapies approved for both indications—TNF inhibitors, IL-12/23 inhibitors, and IL-23 inhibitors—while recommending against IL-17 inhibitors in this population.

Pregnancy guidance specified that certolizumab pegol or narrowband ultraviolet B phototherapy should be offered first when systemic treatment is needed during pregnancy. Acitretin, methotrexate, psoralen plus ultraviolet A light therapy, apremilast, and deucravacitinib were recommended against during pregnancy. Notably, the guidelines clarified that methotrexate may be continued in men trying to conceive, based on published outcome data from children conceived by men taking the drug at or within 3 months of conception.

Study Limitations and Unresolved Clinical Questions

The working group acknowledged that criteria for initiating systemic treatment, treatment goals, and evaluation of treatment response were not reevaluated in this update. Several clinically important questions remained unresolved due to insufficient evidence, including the optimal positioning of deucravacitinib within the treatment algorithm, treatment options for people undergoing hemodialysis, management of paradoxical psoriasis induced by anti-TNF agents, and whether early treatment initiation could be broadly recommended. The guidelines are scheduled for revision by 2030. Five of 22 working group members disclosed conflicts of interest, primarily conference invitations and speaking roles with pharmaceutical manufacturers.

The guidelines did not address topical treatments or psoriasis management in children. According to the authors, the update was designed to give dermatologists "a clear therapeutic algorithm incorporating the latest treatments, tailored to patients' comorbidities."

Reference

1. Regnault MM, Brenaut E, Marniquest M-E, et al. French guidelines on systemic treatments for moderate‐to‐severe psoriasis in adults: update 2025. J Eur Acad Dermatol Venereol. 2025;40(6):963-979. doi:10.1111/jdv.70263