A painful pustular flare can follow stopping biologics in psoriasis

Design

Multicentre observational study of biologic discontinuation episodes (2011-2025), GEE model

Population

1,198 biologic-treatment episodes in plaque psoriasis patients who discontinued therapy

Primary outcome

A distinct pustular psoriasis flare after withdrawal

Effect

Occurred in 86/1,198 (7.2%); risk rose with repeated withdrawal-relapse cycles

Stopping a biologic in psoriasis is common, whether planned, enforced by access, or driven by remission. This multicentre study of discontinuation episodes between 2011 and 2025 describes a distinct and severe flare phenotype that can follow it, and identifies who is most at risk.

The flare, painful diffuse erythema with pustules and swelling, mostly on the lower limbs, occurred in 86 of 1,198 treatment episodes (7.2%). It became more likely with each additional cycle of withdrawal and relapse. Independent risk factors were a family history of psoriasis, concomitant psoriatic arthritis, a previous episode of this flare, more prior withdrawal-relapse cycles, and a longer time to reach PASI 50 during biologic therapy.

The practical message is to recognise the phenotype and to plan withdrawals carefully, especially in patients with these features. In higher-risk patients, watch closely after stopping a biologic and resume treatment early if this flare appears, rather than treating it as ordinary relapse.

• A distinct pustular flare followed biologic withdrawal in 7.2% (86/1,198) of discontinuation episodes.
• It presents as painful, diffuse erythema with pustules and swelling, predominantly on the lower limbs.
• Risk rose with repeated withdrawal-relapse cycles.
• Family history, psoriatic arthritis, a prior such flare and slow initial response marked higher risk.
• In at-risk patients, monitor closely after stopping a biologic and resume early if this flare develops.

Why it matters

It reframes biologic withdrawal as carrying a specific, recognisable hazard, not just a return to baseline plaques.

Don't overread it

This was a non-randomised observational study without molecular confirmation; the associations guide vigilance, they do not establish that any factor causes the flare.

The statistics, in plain English

The risk factors come from an observational model, so they identify associations rather than proving cause; the 7.2% rate is across treatment episodes, not individual patients, so an individual with several cycles may face a higher chance.

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