- Design
- Multicentre retrospective cohort of biologic withdrawal episodes
- Population
- 1,198 biologic withdrawal episodes in plaque psoriasis responders, 2011 to 2025
- Primary outcome
- Distinct pustular psoriasis flare after withdrawal
- Effect
- 86 of 1,198 episodes (7.2%); five independent risk factors identified
A multicentre cohort study in the Journal of the American Academy of Dermatology, published on 25 September, followed patients with plaque psoriasis who had responded to a biologic and then stopped it, between 2011 and 2025.
A distinct pustular flare followed 86 of 1,198 withdrawals (7.2%). It was painful, with diffuse intense redness, pustules and swelling, mostly on the lower legs. It became more likely with each cycle of stopping and relapsing. Five features were independently associated with it: a family history of psoriasis, psoriatic arthritis, a previous flare of this type, more previous withdrawal–relapse cycles, and a slower time to PASI 50 on the biologic.
The practical change is in how a biologic holiday is planned. Patients often stop for cost, pregnancy plans, infection or simply because they are clear. For those with these features, the authors recommend close monitoring and early restarting. Repeated on–off cycles appear to increase the risk.
The study was observational, without random allocation, and lacked histology, so the flares were defined clinically. In India, where many patients pay for biologics themselves and stop when the money runs out, this is a common scenario and a reason to plan the exit.
- Before stopping a biologic, check for a family history of psoriasis, psoriatic arthritis and any previous pustular flare.
- Consider avoiding repeated on–off cycles in patients who have already relapsed after stopping.
- Warn patients with these features about painful red, swollen, pustular skin on the legs, and to return early if it appears.
- Arrange early review after stopping, and consider restarting promptly at the first sign of a flare.
- Where cost forces a stop, discuss a planned transition to a conventional systemic rather than an abrupt halt.
Why it matters
Biologic holidays are often treated as risk-free; for some patients they carry a real chance of a severe pustular flare.
Don't overread it
This is an observational association; it cannot show that a particular stopping strategy prevents flares.
The statistics, in plain English
7.2% is a per-withdrawal rate, not a per-patient rate, and patients who stopped several times contributed several episodes. The risk factors were identified by a model that accounts for repeated episodes in the same person, but they predict risk rather than prove cause.
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