Among patients with psoriasis, the interleukin (IL)-23 inhibitors risankizumab, guselkumab, and ustekinumab showed the lowest 3-year risk for progression to psoriatic arthritis (PsA) compared with other immunomodulators, in a comparative risk analysis.

The findings were presented in one of the prize-winning posters at the American Academy of Dermatology (AAD) 2026 Annual Meeting.

“Early IL-23 use may delay or prevent PsA onset,” two of the study authors, Madelyn Schmidt and Ayezel Munoz, MD, of the University of Texas Medical Branch, Galveston, Texas, told Medscape Medical News.

The study identified patients from the TriNetX Research Network who were diagnosed with psoriasis and were being treated with immunomodulators, including TNF inhibitors (adalimumab, infliximab, certolizumab pegol, etanercept); IL-17 inhibitors (ixekizumab, secukinumab); and IL-23 pathway agents (tildrakizumab, risankizumab, guselkumab, ustekinumab).

Patients on each immunomodulator were propensity score-matched to patients on the others and compared for their 3-year risk of developing PsA. Propensity score-matching was based on demographics, socioeconomic factors, obesity, inflammatory bowel disease, gout, diabetes mellitus, hypertension, hyperlipidemia, tobacco use, and alcohol-related disorders.

Cox proportional hazards modeling showed that for patients on adalimumab vs risankizumab, guselkumab, or ustekinumab, the hazard ratios (HRs) of developing PsA were 2.46 (95% CI, 1.97-3.08), 1.42 (95% CI, 1.10-1.83), and 1.72 (95% CI, 1.45-2.05), respectively.

Likewise, for patients on secukinumab vs those on risankizumab, guselkumab, or ustekinumab, the HRs of developing PsA were 2.39 (95% CI, 1.86-3.06), 1.55 (95% CI, 1.19-2.00), and 1.87 (95% CI, 1.52-2.29), respectively.

Compared with risankizumab, guselkumab, or ustekinumab certolizumab pegol was associated with a greater PsA risk, with HRs of 3.92 (95% CI, 2.28-6.77), 2.19 (95% CI, 1.37-3.49), and 1.98 (95% CI, 1.27-3.09), respectively, and tildrakizumab was not associated with a significantly higher risk for PsA.

Risankizumab was linked to a significantly decreased risk for PsA compared with etanercept (HR, 0.33; 95% CI, 0.26-0.42) and guselkumab (HR, 0.64; 95% CI, 0.47-0.87).

Asked to comment on the findings, Rebecca Haberman, MD, a rheumatologist who is associate director of the Psoriatic Arthritis Center at NYU School of Medicine, New York City, told Medscape Medical News that “while these findings are intriguing, what this means clinically is still unclear.”

Haberman, who was not involved with the study, is the lead investigator of the Preventing Psoriatic Arthritis Cohort, which follows patients with psoriasis to better understand factors associated with progression to PsA, and the PAMPA trial (Preventing Arthritis in a Multi-Center Psoriasis At-Risk Cohort), which is the first clinical trial to look at the use of biologics to prevent progression in patients with psoriasis.

“One of the difficulties in interpreting these results is that we don’t know why these medications were initially chosen for the patients,” Haberman explained. “The IL-17 and TNF inhibitors are stronger medications on the joints compared to the IL-23 medications, but the IL-23 medications can help with psoriatic arthritis. So, often times, if a patient already has some pain, even if they are not officially diagnosed with psoriatic arthritis, the provider may opt for the medication that is stronger on joints,” she added.

“It may be, for example, that patients with joint pain or at high risk for psoriatic arthritis were more likely to be prescribed IL-17 or TNF inhibitors compared with medications like risankizumab, guselkumab, and ustekinumab. Therefore, while it might appear that IL-23 inhibitors decrease the risk of PsA, instead this may be a reflection of a provider’s clinical judgment,” Haberman noted. “Ultimately, this is a great starting point and can be considered but should not yet be used to guide clinical practice. More prospective trials are needed to confirm and validate these findings.”

The authors had no disclosures or commercial support to report. Haberman disclosed consultancy work for J&J, Novartis, and UCB.

Kate Johnson is a Montreal-based freelance medical journalist who has been writing for more than 30 years about all areas of medicine.