The key to effective psoriasis treatment may lie in understanding our biological age.
Imagine two patients with the same severe psoriasis, receiving the same biologic medication. One sees clear skin for years, while the other switches treatments repeatedly due to side effects or ineffectiveness. What explains this dramatic difference? Groundbreaking research reveals that a patient's age significantly influences treatment success, challenging the one-size-fits-all approach to psoriasis care.
For the millions living with moderate-to-severe psoriasis, biologic therapies have been revolutionary. These targeted treatments block specific immune system proteins that drive inflammation. However, clinicians have long observed that treatment outcomes vary widely across different age groups. Until recently, this critical factor wasn't systematically studied, leaving doctors without clear guidance for personalizing treatment based on age.
Patients Analyzed
Age Groups Studied
Follow-up Period
The British Association of Dermatologists Biologics and Immunomodulators Register (BADBIR), one of the world's largest psoriasis registries, has now uncovered striking patterns in how age affects treatment durability. Their findings, drawn from over 14,000 patients, are transforming how dermatologists select biologics for patients of all ages 1 .
Psoriasis isn't just a skin condition—it's a chronic inflammatory systemic disease affecting at least 60 million people worldwide. The visible plaques and scales result from an overactive immune response, primarily driven by specific inflammatory pathways involving cytokines like TNF-alpha, IL-23, and IL-17.
Biologics work by precisely targeting immune components. TNF-alpha inhibitors (like adalimumab and etanercept), IL-17 inhibitors (like secukinumab), and IL-23 inhibitors (like guselkumab) have dramatically improved treatment outcomes.
Our immune systems change throughout our lives, a concept known as immunosenescence. Younger patients typically have more robust immune responses, while older patients often have multiple health conditions and take various medications.
The BADBIR study introduced a crucial metric: "drug survival"—how long patients continue a treatment before stopping due to either ineffectiveness or adverse events. This real-world measure provides valuable insights into long-term treatment success beyond controlled clinical trials, which often exclude older patients with complex health profiles 2 .
To understand how age affects biologic treatment durability, researchers analyzed data from 14,294 psoriasis patients in the UK and Ireland who started their first biologic treatment between 2007 and 2024. Patients were categorized into seven age groups to detect subtle variations across the lifespan:
The 45-54 age group served as the reference for comparisons. Researchers used sophisticated statistical models to analyze how long patients remained on four classes of biologics, tracking whether discontinuations resulted from lack of effectiveness or adverse events, while accounting for other factors like weight, disease severity, and previous treatments.
The results revealed clear patterns that should inform treatment decisions:
| Age Group | Primary Reason for Stopping | Most Affected Biologic Classes |
|---|---|---|
| 16-24 years | Ineffectiveness | TNF-alpha inhibitors |
| 55-64 years | Adverse Events | TNF-alpha inhibitors, IL-12/23 inhibitors |
| 65-74 years | Adverse Events | TNF-alpha inhibitors, IL-12/23 inhibitors, IL-17 inhibitors |
| 75+ years | Adverse Events | All classes |
These findings highlight a critical divergence: younger patients struggle more with treatment effectiveness, while older patients face greater challenges with treatment safety.
The BADBIR study employed rigorous methodology to ensure its findings would be clinically relevant 3 .
Dermatologists across the UK and Ireland enrolled patients starting first-time biologic treatment for psoriasis, collecting comprehensive baseline data including demographics, medical history, disease characteristics, and previous treatments.
Patients were followed at 6-month intervals for up to 8 years, with detailed documentation of treatment changes, effectiveness measures (PASI scores), adverse events, and reasons for discontinuation.
Researchers used flexible parametric survival models to compare treatment durability across age groups, adjusting for potential confounding factors like weight, disease duration, and psoriatic arthritis.
The analysis produced striking revelations about treatment patterns across ages. Younger patients' higher discontinuation due to ineffectiveness suggests their disease may be biologically different or more aggressive, requiring more potent targeted therapy. Older patients' increased sensitivity to adverse events likely reflects age-related changes in drug metabolism, existing health conditions, and concurrent medications.
Higher discontinuation due to ineffectiveness suggests their disease may be biologically different or more aggressive.
Increased sensitivity to adverse events likely reflects age-related changes in drug metabolism and existing health conditions.
Perhaps most notably, the research identified that IL-23 inhibitors showed more consistent effectiveness across age groups, with age-related differences primarily appearing in adverse event rates rather than effectiveness 4 .
For younger patients with psoriasis, particularly those in their teens and twenties, starting with TNF-alpha inhibitors might lead to disappointing results and treatment switches. Instead, newer biologic classes like IL-17 or IL-23 inhibitors might offer better long-term control.
For older patients, especially those over 55, the message isn't to avoid biologics—they remain highly effective—but to implement closer monitoring for potential side effects. This might mean more frequent check-ins, additional safety screenings, and heightened awareness of potential drug interactions.
These findings align with smaller studies, including recent research showing that biologic treatments demonstrate both efficacy and safety in elderly patients, with some agents like guselkumab exhibiting excellent drug survival when initiated after age 65 5 .
The BADBIR study represents a significant shift toward personalized medicine in dermatology. By recognizing that age significantly influences treatment success, we can move beyond trial-and-error approaches to more strategic treatment selection.
Future research will likely focus on understanding the biological mechanisms behind these age-related differences. Does the immune pathology of psoriasis differ between young and old? Do age-related changes in metabolism or organ function affect drug processing? Answering these questions could lead to even more tailored approaches.
As one of the researchers noted, "Biologics are effective in older people with plaque psoriasis. However, there needs to be strict monitoring for adverse events" 6 . This balanced approach—maximizing benefits while minimizing risks—represents the new frontier in psoriasis care.
For patients of all ages living with psoriasis, these findings bring hope for more effective, personalized treatment strategies that account for their unique biological characteristics, not just their symptoms.
The message is clear: in psoriasis treatment, age isn't just a number—it's a crucial factor in crafting successful, long-term treatment plans.