A LARGE real-world cohort study using data from the British Association of Dermatologists Biologic Interventions Register (BADBIR) has examined the risk of serious infections associated with systemic treatments for psoriasis, offering reassurance overall while highlighting some treatment-specific signals.
Psoriasis Systemic Treatments and Infection Risk
Systemic therapies for psoriasis, including biologics and small molecules, are known to modulate the immune system and may increase susceptibility to infection. To better quantify this risk, researchers analysed 46,770 treatment episodes from 18,976 adult patients recorded in BADBIR. Patients were followed from treatment initiation until discontinuation, death, or last follow-up, with serious infections defined as those requiring hospitalisation, intravenous antimicrobial therapy, or resulting in death. Importantly, infections occurring during treatment or within 90 days after treatment discontinuation were included in the analysis.
The cohort was predominantly male (57.4%), with a mean age of 45.6 years and an average BMI of 31.6 kg/m². Over the study period, the incidence of serious infection was 27.67 events per 1,000 person-years. Among patients with a prior infection, the rate of recurrent serious infection was notably higher, at 78.70 events per 1,000 person-years.
Using a piecewise Cox proportional hazards model, the investigators identified an increased risk of serious infection associated with apremilast and secukinumab when compared with adalimumab. However, these findings were not consistent across sensitivity analyses, suggesting some uncertainty around these associations.
Recurrent Event Analysis Strengthens Findings
To provide a more robust assessment, the researchers conducted a recurrent event analysis using the Prentice-Williams-Peterson model. This approach, which accounts for multiple infection events in the same patient, found that risankizumab was associated with a significantly lower risk of serious infections compared with several alternatives, including brodalumab, etanercept, and standard systemic therapies.
Importantly, deaths linked to serious infections were rare, with an incidence rate of 1.81 per 1,000 person-years.
Overall, the findings suggest that while certain therapies may show isolated signals of increased infection risk, the broader evidence does not indicate major differences in risk across most systemic treatments. The reduced risk observed with risankizumab in recurrent event analyses may be clinically relevant, particularly for patients at higher baseline risk of infection.
Clinical Implications for Psoriasis Management
These results provide valuable real-world evidence to support treatment selection and risk stratification in psoriasis, reinforcing the importance of individualised decision-making when prescribing systemic therapies.
Reference
Bright HRB et al. Serious infection risk with systemic treatments for psoriasis: A cohort study from the British Association of Dermatologists Biologic Interventions Register (BADBIR). Br J Dermatol. 2026; DOI: 10.1093/bjd/ljag174.
Featured image: joey333 on Adobe Stock
