Palmoplantar psoriasis: adalimumab, guselkumab, ixekizumab and secukinumab beat placebo

Design

Bayesian network meta-analysis of 20 randomised trials

Population

2,158 adults with palmoplantar psoriasis or palmoplantar pustulosis

Primary outcome

ppPASI 75 or equivalent PGA 0/1 at week 14 to 16

Effect

Versus placebo: adalimumab OR 6.8 (95% CrI 1.5 to 31), ixekizumab 10.0 (2.2 to 44), secukinumab 6.1 (1.7 to 27)

This Bayesian network meta-analysis pooled 20 randomised trials with 2,158 adults who had palmoplantar psoriasis or palmoplantar pustulosis. The primary outcome was ppPASI 75, or an equivalent physician global score of 0 or 1, at weeks 14 to 16.

Against placebo, the odds of response were higher with adalimumab (OR 6.8, 95% credible interval 1.5 to 31), ixekizumab (OR 10.0, 2.2 to 44) and secukinumab (OR 6.1, 1.7 to 27); guselkumab 100 mg also did better (OR 7.4). Ixekizumab ranked highest (SUCRA 87.2%), then guselkumab 100 mg (84.1%), adalimumab (76.5%) and secukinumab (71.3%). People with disease confined to the palms and soles responded less well.

The credible intervals are very wide and overlap, so the ranking cannot separate these four. The data are indirect comparisons from varied populations, and the authors say so. For a patient with disabling palmoplantar disease, the review supports using an IL-17, IL-23 or TNF agent, with choice driven by comorbidity, access and cost.

• For disabling palmoplantar disease despite topicals, consider an IL-17, IL-23 or TNF inhibitor.
• Do not read the ranking as proof that one drug beats another; the intervals overlap widely.
• Counsel that exclusive palm and sole disease responded less well than psoriasis elsewhere.
• Judge response at 14 to 16 weeks with a palmoplantar-specific score, not body PASI.
• Separate pustular from plaque phenotypes; trials mixed them.

Why it matters

Palmoplantar disease is often undertreated because body-surface scores look mild, and this gathers the biologic evidence in one place.

Don't overread it

Indirect comparisons across heterogeneous trials cannot establish that one biologic is superior.

The statistics, in plain English

A credible interval of 1.5 to 31 means the true odds ratio could plausibly be anywhere from slightly above 1 to over 30. SUCRA is a ranking score; it can place one drug above another even when their results overlap almost completely, as here.

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