- Matthew Vesely, MD, PhD
- Comorbidities, Expert Insights
- Professor Ryan is a Consultant Dermatologist at the Institute of Dermatologists and a Clinical Professor at University College Dublin.
- She co-founded the Institute of Dermatologists in 2019.
- Professor Ryan has authored a textbook on psoriasis, seven book chapters, an encyclopedia chapter, and over 70 articles in peer-reviewed medical journals.
- She has conducted both scientific and clinical research on psoriasis and has served as the Principal Investigator for multiple drug trials in psoriasis and eczema.
Understanding the Link Between Psoriasis and Malignancy
The relationship between psoriasis and malignancy has long been a topic of both clinical concern and scientific interest. Chronic systemic inflammation, immune dysregulation, and historical therapies such as PUVA and cyclosporine have all contributed to a perception of elevated cancer risk among psoriasis patients. Recent data from modern biologic and real-world registries, however, suggest a more reassuring picture. While multiple studies have evaluated cancer risk in psoriasis, the data are heterogeneous and often confounded by lifestyle and treatment variables. For example, a meta-analysis involving 112 studies that included over two million patients with psoriasis or psoriatic arthritis found that people with psoriasis have a minimal increased risk of developing cancer with a relative risk (RR) of 1.21.1 A separate meta-analysis of 20 cohort studies, which included 851,942 patients with psoriasis and 7,974,047 controls, showed no significant increased risk of malignancy, with a hazard ratio (HR) of 1.02.2
Impact of Psoriasis Treatment on Cancer Risk
Traditional treatments for psoriasis that included PUVA and cyclosporin increased the risk of cancer. Currently, moderate to severe psoriasis is often treated with immunomodulatory biologic drugs or small-molecule inhibitors. Multiple studies have reassuring data that biologic therapy targeting TNFα, IL-17A, and IL-23 does not increase the risk of developing cancer.1,3-10 Nevertheless, patient perception of adverse events to these medications persists, including the risk of cancer development.
When counselling patients with psoriasis about systemic therapies and cancer risk, Prof. Ryan aims to offer “a balanced, evidence-based and reassuring discussion.” As many patients are understandably concerned about how long-term treatment might influence their risk of developing or recurring malignancy, “fortunately, we now have a wealth of high-quality data that allows us to counsel with confidence,” says Prof. Ryan.
“I explain that modern biologic therapies have transformed our ability to treat psoriasis safely and effectively. The most reassuring data come from agents targeting anti-IL-17 and anti-IL-23. Multiple long-term studies and pooled safety analyses involving tens of thousands of patient years have shown no increase in overall cancer incidence with these therapies. In fact, patients treated with these agents often appear to have a lower observed risk of malignancy compared to those with untreated or undertreated systemic inflammation, likely due to the beneficial effect of controlling chronic immune activation.”
In terms of tumor necrosis factor inhibitors, there has been some “historical debate regarding a possible association with lymphoma.” However, Prof. Ryan explains that “more recent studies in psoriasis populations have not demonstrated a consistent or significant increase in lymphoma risk.” Nevertheless, Prof. Ryan takes care to consider individual patient risk factors and “discuss treatment choices collaboratively, especially in those with a previous history of lymphoproliferative disease.”
“With all patients, I emphasize that psoriasis itself is a chronic inflammatory disease that carries its own risks, including cardiovascular and metabolic comorbidities. Effective disease control with systemic therapy not only improves skin and joint symptoms but also contributes to broader health and wellbeing.”
Ultimately, Prof. Ryan explains that she is “able to confidently reassure patients that our current biologic options, particularly anti-IL-17 and anti-IL-23 agents, provide highly effective disease control without significantly increasing cancer risk.”
Treating Psoriasis in Patients with a History of Cancer
Treating psoriasis in patients with a prior cancer diagnosis is a common and often anxiety-provoking scenario. Prof. Ryan describes how she navigates these situations collaboratively.
“We always coordinate closely with their oncology team to ensure our treatment plan aligns with their cancer surveillance and recovery goals.” Prof. Ryan notes that there are several important factors when selecting psoriasis treatments in patients with a history of cancer, including “the type and stage of the previous malignancy, the interval since diagnosis, oncologic prognosis, and whether the patient remains under surveillance.”
When selecting a therapy, Prof. Ryan prioritizes agents with the “most favorable safety profiles, particularly IL-17 and IL-23 inhibitors, based on long-term clinical trial data, registry studies, and mechanistic understanding. Their ability to provide rapid, durable psoriasis control without broadly suppressing the immune system makes them particularly well suited to this population.” A recent international survey of psoriasis experts conducted by the International Psoriasis Council,11 in which consultants with deep clinical experience “consistently selected anti-IL-17 and anti-IL-23 therapies as the most frequently preferred options for patients with a prior malignancy, particularly when the diagnosis was over five years ago. Their responses reflect a synthesis of guideline familiarity, evidence appraisal, and real-world patient management.”
Prof. Ryan’s management is highly individualized as she considers “disease severity, patient preference, comorbidities, and psychosocial context”. The goal is “always to deliver effective, evidence-based psoriasis care without compromising oncologic safety with open communication and shared decision-making.” Overall, the data are reassuring as several long-term clinical studies and registry data have demonstrated no increased risk of malignancy or recurrence in patients treated with anti-IL-17 and anti-IL-23 therapies, even in those with a history of cancer. This aligns with the EuriGuiDerm guidelines for treating psoriasis patients with a history of cancer, where there is a strong consensus to recommend nbUVB and acitretin followed by methotrexate, apremilast, and biologics targeting TNF, IL-17, and IL-23.12 Consensus guidelines do not recommend the use of cyclosporin in psoriasis patients with a previous history of cancer, especially SCC.”12,13 The IPC survey results support this approach.11 Most experts reported they consult oncology colleagues when prescribing systemic therapy within five years of a malignancy diagnosis. “I find that this collaborative framework helps patients feel secure in their treatment decisions,” notes Prof. Ryan.
Treating Psoriasis in Patients with Active Cancer: Challenges and Considerations
Treating psoriasis in the context of active malignancy or ongoing oncologic therapy requires thoughtful, individualized care that carefully balances the need for effective disease control with absolute oncologic safety. This is an increasingly common scenario, particularly as patients live longer with both cancer and chronic inflammatory skin disease.
“My first step,” says Prof. Ryan, “is always to communicate directly with the patient’s oncology team. This collaborative approach ensures transparency and provides clarity on the type and intensity of the cancer treatment, prognosis, and whether immunosuppression would pose a significant risk in that context. Many oncologists are not as familiar with psoriasis treatments and appreciate a shared decision-making approach.”
It is also important to recognize that for patients with severe psoriasis and a diagnosis of malignancy, “untreated psoriasis significantly impacts physical, psychological, and social wellbeing as visible plaques, skin discomfort, and functional limitations can contribute to social stigma, isolation, and mental health challenges.” When combined with the emotional and physical toll of a malignancy diagnosis, the withdrawal of effective psoriasis treatments “compounds their suffering and further reduces quality of life.” Prof. Ryan thinks it is imperative to “address this dual burden with evidence-based strategies that balance oncologic safety with improving dermatologic outcomes.”
From a treatment perspective, several non-immunosuppressive options may be appropriate for patients with active cancer. “Narrowband ultraviolet B phototherapy is often my first-line approach if logistically feasible as it provides reliable control for many patients without systemic exposure and has an excellent safety profile.” When phototherapy is not an option. Systemic therapy is necessary, the choice “must be highly individualized” says Prof. Ryan. While historically biologics were avoided in patients undergoing active cancer treatment, “the data are increasingly reassuring for selected agents, particularly the IL-17 and IL-23 inhibitors.”14-17 In the recent IPC survey of 57 global psoriasis experts, apremilast, anti-IL-17, and anti-IL-23 therapies were the most frequently selected biologic options for patients with active malignancy, particularly for those with low-grade or indolent cancers such as stage one breast cancer or superficial melanoma.11
Ultimately, Prof. Ryan’s guiding principle is to “respect the oncologic landscape while not abandoning the patient’s need for psoriasis care.” With careful communication, growing safety data, and a broadening therapeutic toolkit, we are increasingly able to support these patients with confidence and compassion.”
For patients undergoing immunotherapy, such as immune checkpoint inhibitors, psoriasis flares may occur or worsen. In these cases, the goal is to control the skin disease without interrupting the anticancer regimen. Prof. Ryan notes that “acitretin, phototherapy, and selective biologics can often be used successfully without compromising cancer therapy.”18,19
Future Directions and Clinical Pearls
Understanding the interface between psoriasis and malignancy remains an active area of research. Prof. Ryan discussed that “as our therapeutic landscape continues to evolve, so too must our understanding of the relationship between psoriasis, malignancy, and immunomodulatory therapy.” While existing data are broadly reassuring, key research priorities remain. “Most safety analyses to date often exclude patients with a cancer history. We urgently need high-quality, prospective, real-world data on the long-term safety of psoriasis treatments in patients with previous or active malignancy”. Furthermore, Prof. Ryan emphasizes the need for “global harmonization of data collection and linkage to cancer registries.”
Addressing this evidence gap “will enable more confident prescribing and clearer guidance.”
There is an ongoing need to understand the immunological mechanisms linking chronic inflammation with tumor surveillance, as “psoriasis is a complex immune-mediated condition, and its interplay with the tumor microenvironment remains incompletely understood.” Studying how biologic agents modulate immune responses in patients with cancer may help to clarify their true impact on oncogenesis and tumor progression.
“Personalized medicine must remain a focus as no two cancer histories are alike, and risk tolerance varies between patients and oncologists. We need validated tools and guidelines that account for cancer type, stage, treatment history, and latency, while also incorporating the severity and burden of psoriasis. The integration of artificial intelligence and multi-omic data may ultimately help stratify patient risk and optimize treatment pathways.”
Finally, global expert collaboration is critical. “The recent International Psoriasis Council (IPC) malignancy survey, in which 57 expert councilors shared their collective clinical approach to prescribing in the setting of malignancy, reflects a growing consensus that anti-IL-17 and anti-IL-23 therapies appear to offer the most favorable balance of efficacy and safety in these complex cases. This expert-derived insight adds valuable real-world context to the emerging data and should inform future clinical guidelines.”
For practicing clinicians, “the key message is one of cautious confidence. We now have robust treatment options that can be safely and effectively used in patients with a cancer history or those undergoing oncologic therapy. Thoughtful collaboration with oncology, individualized patient assessment, and awareness of the evolving evidence base are essential. With these principles in mind, we can support our patients holistically and without unnecessary delay.”
References
- Vaengebjerg S, Skov L, Egeberg A, et al. Prevalence, Incidence, and Risk of Cancer in Patients With Psoriasis and Psoriatic Arthritis: A Systematic Review and Meta-analysis. JAMA Dermatol. Apr 1 2020;156(4):421–429. doi:10.1001/jamadermatol.2020.0024.
- Yang Y, Zhang Q, Huang A, et al. All-Cause and Cause-Specific Mortality in Psoriasis Patients: A Systematic Review and Meta-Analysis. Front Immunol. 2025;16:1610499. doi:10.3389/fimmu.2025.1610499.
- Waljee AK, Higgins PD, Jensen CB, et al. Anti-Tumour Necrosis Factor-Alpha Therapy and Recurrent or New Primary Cancers in Patients With Inflammatory Bowel Disease, Rheumatoid Arthritis, or Psoriasis and Previous Cancer in Denmark: A Nationwide, Population-Based Cohort Study. Lancet Gastroenterol Hepatol. Mar 2020;5(3):276–284. doi:10.1016/S2468-1253(19)30362-0.
- Wu WT, Chiang MC, Huang YC. The Risk of Malignancy in Patients With Psoriasis Treated With Long-Term Tumour Necrosis Factor-Alpha Inhibitors: A Systematic Review and Meta-Analysis. Clin Exp Dermatol. Apr 24 2025;50(5):968–980. doi:10.1093/ced/llae503.
- Lebwohl M, Deodhar A, Griffiths CEM, et al. The Risk of Malignancy in Patients With Secukinumab-Treated Psoriasis, Psoriatic Arthritis, and Ankylosing Spondylitis: Analysis of Clinical Trial and Postmarketing Surveillance Data With Up to Five Years of Follow-Up. Br J Dermatol. Nov 2021;185(5):935–944. doi:10.1111/bjd.20136.
- Merola JF, Papp KA, Deodhar A, et al. Ixekizumab and Malignant Neoplasms: A Pooled Analysis of Data From 25 Randomized Clinical Trials. JAMA Dermatol. Jul 9 2025;doi:10.1001/jamadermatol.2025.2056.
- Blauvelt A, Lebwohl M, Langley RG, et al. Malignancy Rates Through 5 Years of Follow-up in Patients with Moderate-to-Severe Psoriasis Treated with Guselkumab: Pooled Results from the VOYAGE 1 and VOYAGE 2 Trials. J Am Acad Dermatol. Aug 2023;89(2):274–282. doi:10.1016/j.jaad.2023.03.035.
- Peleva E, Exton LS, Kelley K, et al. Risk of Cancer in Patients with Psoriasis on Biological Therapies: A Systematic Review. Br J Dermatol. Jan 2018;178(1):103–113. doi:10.1111/bjd.15830.
- Ro C, Ormaza Vera A, Adawi W, Yap A, Enos CW. Assessment of Primary Malignancy Risk after Initiation of Biologic Therapy in Patients with Psoriasis. JID Innov. Nov 2025;5(6):100397. doi:10.1016/j.xjidi.2025.100397.
- Takamura S, Saito S, Sugai S, et al. Biologic Therapy and Malignancy Risk in Psoriasis: A Retrospective Cohort Study. J Dermatol. Sep 8 2025;doi:10.1111/1346-8138.17950.
- Bowe S, Murphy M, Bourke J, Ryan C. Prescribing Practices Among Psoriasis Experts for Patients With Concomitant Malignancy: A Survey of International Psoriasis Council Members. Clin Exp Dermatol. Aug 22 2025;50(9):1818–1826. doi:10.1093/ced/llaf198.
- Nast A, Smith C, Spuls PI, et al. EuroGuiDerm Guideline on the Systemic Treatment of Psoriasis Vulgaris – Part 2: Specific Clinical and Comorbid Situations. J Eur Acad Dermatol Venereol. Feb 2021;35(2):281–317. doi:10.1111/jdv.16926.
- Papp KA, Melosky B, Sehdev S, et al. Use of Systemic Therapies for Treatment of Psoriasis in Patients with a History of Treated Solid Tumours: Inference-Based Guidance from a Multidisciplinary Expert Panel. Dermatol Ther (Heidelb). Apr 2023;13(4):867–889. doi:10.1007/s13555-023-00905-3.
- Lanna C, Rivieccio A, Vultaggio M, et al. Efficacy and Safety of Apremilast in Oncological Patients with Moderate-to-Severe Plaque Psoriasis: A 5 years Retrospective Observational Study. Clin Cosmet Investig Dermatol. 2025;18:1231–1238. doi:10.2147/CCID.S499658.
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- To SY, Lee CH, Chen YH, et al. Psoriasis Risk With Immune Checkpoint Inhibitors. JAMA Dermatol. Jan 1 2025;161(1):31–38. doi:10.1001/jamadermatol.2024.4129.
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