The management of moderate to severe psoriasis has been transformed over the past two decades by the advent of biologic therapies. These targeted agents have delivered unprecedented efficacy and improved quality of life for millions of patients. However, their use in individuals with active cancer or a recent history of malignancy has long remained a source of clinical uncertainty.

Concerns about immune modulation, tumor surveillance, and cancer recurrence have traditionally led clinicians to favor conventional systemic agents—or to delay treatment altogether—in this vulnerable population. New evidence now suggests that these fears may be overstated. Recent data indicate that biologic therapies demonstrate safety comparable to conventional systemic treatments in patients with psoriasis who have active cancer or a recent cancer history.

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A Longstanding Clinical Dilemma

Psoriasis is a chronic, immune-mediated inflammatory disease that often requires systemic therapy for adequate control. At the same time, psoriasis patients may have an elevated baseline risk of certain malignancies due to chronic inflammation, shared risk factors, or prior exposure to immunosuppressive therapies.

Historically, biologics—particularly tumor necrosis factor (TNF) inhibitors—were approached with caution in patients with cancer because of their effects on immune pathways involved in tumor surveillance. As a result, many clinicians have relied on older systemic agents such as methotrexate, cyclosporine, or acitretin, despite their own well-documented toxicities.

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New Evidence on Safety Outcomes

Recent observational studies and registry-based analyses provide reassuring data. In patients with psoriasis who had active malignancy or a recent cancer history, biologic therapies were associated with:

• Comparable cancer progression rates

• Similar cancer recurrence rates

• No significant increase in overall malignancy-related adverse outcomes

Importantly, these outcomes were similar to those observed in patients treated with conventional systemic agents, suggesting that biologics do not confer additional oncologic risk in this context.

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Understanding the Mechanisms

Modern biologic therapies target specific immune pathways—such as TNF-α, interleukin (IL)-17, IL-23, and IL-12/23—rather than broadly suppressing immune function. This targeted approach may explain why biologics do not appear to significantly impair anti-tumor immune surveillance compared with traditional immunosuppressants.

Additionally, newer biologics, particularly IL-17 and IL-23 inhibitors, may have a more favorable safety profile than earlier agents, further supporting their use in carefully selected patients with cancer histories.

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Comparison With Conventional Systemic Therapies

Conventional systemic agents have long been considered the “safer” option in patients with cancer, yet they are not without risks:

• Methotrexate is associated with hepatotoxicity, bone marrow suppression, and potential oncologic concerns

• Cyclosporine carries risks of nephrotoxicity, hypertension, and secondary malignancies

• Acitretin has limited efficacy for inflammatory disease and significant teratogenicity

The finding that biologics perform no worse in terms of cancer progression or recurrence challenges long-held assumptions and encourages a more nuanced, individualized approach to treatment selection.

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Implications for Clinical Practice

These findings have important implications for dermatologists, oncologists, and multidisciplinary care teams:

1. Biologics may be considered viable options for psoriasis patients with active or recent cancer when disease severity warrants systemic therapy.

2. Treatment decisions should be individualized, taking into account cancer type, stage, prognosis, and patient preferences.

3. Collaboration with oncology specialists remains essential to ensure coordinated and safe care.

4. Quality of life considerations should not be overlooked, as uncontrolled psoriasis can significantly worsen physical and psychological well-being.

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Remaining Gaps and Future Directions

Despite encouraging data, several unanswered questions remain:

• Are certain biologic classes safer than others in specific cancer types?

• What is the optimal timing of biologic initiation following cancer treatment?

• How do long-term outcomes compare across different malignancies?

Ongoing registry studies and long-term real-world data will be critical in refining guidelines and providing more precise risk stratification.

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Conclusion

Emerging evidence suggests that biologic therapies are not associated with higher cancer progression or recurrence rates compared with conventional systemic agents in patients with psoriasis who have active cancer or a recent history of malignancy. These findings challenge longstanding clinical hesitations and support a more flexible, patient-centered approach to psoriasis management.

While caution and multidisciplinary collaboration remain essential, biologics may offer a safe and effective treatment option for a population that has historically faced limited choices. As the evidence base continues to grow, biologic therapies are likely to play an increasingly important role in the care of psoriasis patients with complex oncologic histories.