We are reporting on the recent FDA approval of icotrokinra, a new oral IL-23 receptor blocker for moderate to severe plaque psoriasis, and what rheumatologists should know during patient evaluation. I’m looking for a brief, on-the-record comment from specialists in rheumatology, dermatology, or psoriatic disease. A short response to any of the questions below would be helpful. What should rheumatologists know right now about icotrokinra before seeing their next patient with psoriasis? Does this approval change how you think about screening for early psoriatic arthritis? What symptoms or exam findings would still prompt a rheumatology workup even if skin disease improves? Which patient is the best fit for this therapy in real-world practice? How do you compare this option with other oral systemic therapies? What safety or monitoring issues should matter most to rheumatologists?

My profile Shamsa Kanwal, M.D., is a board-certified Dermatologist with over 10 years of clinical experience. She currently practices as a consultant Dermatologist at mypsoriasisteam.com/ (USA) Website for backlink: https://www.mypsoriasisteam.com/writers/6841af58b9dc999e3d0d99e7 Q: Does this approval change how you think about screening for early psoriatic arthritis? A: No. From a dermatology perspective, better skin control should not lower the threshold to screen for early psoriatic arthritis. I would still ask about morning stiffness, swollen joints, heel pain, sausage digits, nail changes, and inflammatory back symptoms at routine psoriasis visits, because skin improvement does not reliably rule out evolving joint disease. Q: What symptoms or exam findings would still prompt a rheumatology workup even if skin disease improves? A: I would still refer if a patient has persistent morning stiffness, tender or swollen joints, dactylitis, enthesitis such as heel pain, or inflammatory back pain. Nail pitting and onycholysis also keep psoriatic arthritis on the radar. Q: Which patient is the best fit for this therapy in real-world practice? A: The best fit is a patient with moderate-to-severe plaque psoriasis who is a candidate for systemic therapy or phototherapy and wants an oral option rather than an injectable. It is especially appealing for someone who has not done well with topicals alone, or who has high-impact site disease such as scalp or genital psoriasis. Q: How do you compare this option with other oral systemic therapies? A: What stands out is that icotrokinra is a targeted oral IL-23 receptor blocker, so it is more selective than older oral systemic therapies such as methotrexate or cyclosporine. It also showed superior skin clearance to deucravacitinib, which is notable for an oral psoriasis treatment.

It is important for rheumatologists to note that there is a new oral therapy available for the treatment of plaque psoriasis, which provides another option for patients wanting something different from older oral medications who are not yet ready for injectable treatments. The current FDA label indication is "moderate to severe plaque psoriasis" and does not include psoriatic arthritis, so joint pain, stiffness, and fatigue must still be evaluated and diagnosed separately. [1] Improved skin disease does not reduce the need for thorough initial and ongoing screening for PsA. In fact, it may increase the importance of screening, since it can be challenging to determine whether joint symptoms remain active after skin improvement. PEST is a validated screening tool for PsA, and the National Psoriasis Foundation recommends using it every 6 months. [2] Tender or swollen joints, dactylitis, enthesitis, inflammatory low back pain, reduced range of motion, and nail changes occurring alongside musculoskeletal symptoms are all findings that would lead me to refer a patient to a rheumatologist. If a patient says "My plaques are better, but my hands, feet, or back still hurt," that warrants a more thorough inflammatory workup. [3] The patient I see as a good candidate for icotrokinra is one with skin-predominant disease who is appropriate for systemic treatment and has expressed a preference for oral therapy. This is a different patient population from those whose primary burden of disease comes from active arthritis, enthesitis, or axial symptoms, where treatment strategies should be developed with joint disease in mind. [1][3] Convenience is one of the distinguishing features of icotrokinra compared to other oral systemic therapies, as it is a targeted therapy taken once daily. However, convenience alone does not constitute broad disease coverage, and icotrokinra should not be viewed as an oral treatment option for psoriatic arthritis based on its current labeling. [1] [1] DailyMed. ICOTYDE (icotrokinra) prescribing information. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=aee3c963-edc0-4252-8769-cdf6c7cdc21a [2] National Psoriasis Foundation. Psoriatic Arthritis Screening Test. https://www.psoriasis.org/psoriatic-arthritis-screening-test/ [3] American College of Rheumatology. Psoriatic Arthritis. https://rheumatology.org/patients/psoriatic-arthritis

Icotrokinra has received FDA approval for patients with moderate to severe plaque psoriasis, but not for psoriatic arthritis. The medication works by blocking the IL-23 receptor and is taken orally at 200 mg once daily, on an empty stomach, with food delayed at least 30 minutes after taking it. For rheumatologists, improved skin control should not be read as proof that joint disease is being treated. [1] This FDA approval does not change how patients should be screened for PsA. Since patients with psoriasis can develop inflammatory joint disease even when their skin appears fine, routine screening must continue. The PEST questionnaire remains a valuable screening tool, and the National Psoriasis Foundation recommends it be administered every six months to people with psoriasis. [2] A rheumatologic evaluation is still warranted for persistent morning stiffness, heel or tendon pain suggesting enthesitis, swollen fingers or toes, inflammatory low back pain, nail pitting with joint symptoms, or eye inflammation such as uveitis. Skin improvement with icotrokinra does not rule any of these out. [3] The patient population that best fits icotrokinra is those with moderate to severe plaque psoriasis who want a targeted oral option or have difficulty with, or prefer to avoid, injectable therapy. For patients whose primary burden is joint disease, I would exercise more caution, as the FDA indication is for psoriasis, not arthritis. [1] Compared to other oral systemic therapies, icotrokinra is a targeted therapy rather than a broad immunosuppressant, making it a desirable option for skin-predominant disease. However, since the current indication is for skin, I would not rely on icotrokinra for its effects on joint disease until that data has been established. [1] Key safety considerations include active infection, TB evaluation, and live vaccine contraindications prior to and during treatment. Active infections should be treated before initiating icotrokinra. The most common adverse effects are headache, nausea, cough, fungal infection, and fatigue. [1] [1] DailyMed. ICOTYDE (icotrokinra) prescribing information. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=aee3c963-edc0-4252-8769-cdf6c7cdc21a [2] National Psoriasis Foundation. Psoriatic Arthritis Screening Test. https://www.psoriasis.org/psoriatic-arthritis-screening-test/ [3] American College of Rheumatology. Psoriatic Arthritis. https://rheumatology.org/patients/psoriatic-arthritis

Icotrokinra's approval adds an important oral option for patients with moderate to severe plaque psoriasis, particularly those who prefer to avoid injectables. As an IL-23 receptor blocker, it offers a targeted mechanism that may provide durable skin control with a generally favorable safety profile, but rheumatologists should remember that skin improvement does not always correlate with joint disease control. For rheumatology practice, this reinforces the need for ongoing screening for psoriatic arthritis, even in patients whose skin disease is well managed. Persistent joint pain, morning stiffness, dactylitis, or enthesitis should still prompt a full rheumatologic evaluation regardless of dermatologic response. The patients most likely to benefit are those with moderate to severe skin disease who are hesitant about biologics or who prefer an oral therapy option, provided they are appropriately monitored. Compared with other oral systemic therapies, icotrokinra may offer a more targeted approach, though long-term real-world data will be important to fully define its role. From a safety perspective, rheumatologists should remain attentive to infection risk and ensure appropriate baseline screening and follow-up, consistent with other targeted immunomodulatory therapies.

The approval of icotrokinra introduces a more targeted oral option in the IL 23 pathway, which is particularly relevant for rheumatologists who often see patients at the intersection of skin and joint disease, but it should not create a false sense of security that controlling psoriasis alone will mitigate musculoskeletal risk. Even with improved skin clearance, symptoms such as persistent morning stiffness, enthesitis, dactylitis, or subtle joint swelling should still prompt a rheumatologic evaluation, as psoriatic arthritis can evolve independently of cutaneous severity. From a practical standpoint, the most appropriate candidates are those who need systemic control but prefer an oral agent over injectables, provided their disease profile does not suggest high risk or established joint involvement that may require more aggressive therapy. "Skin improvement is reassuring, but it is not a reliable proxy for what may be developing in the joints." Safety considerations will likely center on class specific immunologic effects and long term data, so coordination between dermatology and rheumatology remains essential to ensure early detection and appropriate escalation if joint symptoms emerge. Erin Zadoorian Co-founder Exhalewell

I'm a double board certified dermatologist, and I've treated psoriasis long enough to know skin clearance and joint risk do not always move together. Rheumatologists should see icotrokinra as a useful new oral option for moderate to severe plaque psoriasis, not as a reason to relax their psoriatic arthritis screen. In the phase 3 trial, 65% reached clear or almost clear skin and 50% reached PASI 90 at 16 weeks. I would still refer any patient with morning stiffness, swollen digits, heel pain, nail pitting, or inflammatory back pain, even when plaques look better. In practice, this fits patients who want an oral therapy with strong skin data and once daily dosing, while monitoring for infection, TB risk, vaccines, and renal impairment.