Biologic Therapy and Superficial Fungal Infection Risk in Moderate-to-Severe Psoriasis: A Meta-Analysis.

Purpose: Biologic agents have become a key treatment option for moderate-to-severe plaque psoriasis; however, the associated risk of superficial fungal infections, such as Candida and dermatophytes infections, remains unclear. This study aims to systematically assess the impact of different biologic agents on these infection risks and to compare the differences between them.

Methods: Research questions and keywords were developed based on the Population, Intervention, Control and Outcome (PICO) framework. A systematic search of PubMed, EMBASE, the Cochrane Library and Web of Science was conducted for randomised controlled trials (RCTs) published up to December 2024, using the keywords 'psoriasis', 'biologics', 'anti-IL-17', 'anti-IL-12/23', 'anti-TNF', 'superficial fungal infections', 'dermatophyte infections', 'Candida' and 'onychomycosis'. Meta-analyses were performed using RevMan 5.4 and STATA 16.0 software.

Results: A total of 644 records were identified, with 29 articles included in the final analysis. Meta-analysis indicated that compared with placebo, interleukin-17 (IL-17) inhibitors notably raised the risk of Candida infections (OR = 2.39, 95% CI = 1.84-3.11, p < 0.00001), whereas tumour necrosis factor-alpha (TNF-α) inhibitors (OR = 1.75, 95% CI = 0.53-5.82, p = 0.36) and interleukin-12/23 (IL-12/23) inhibitors (OR = 1.11, 95% CI = 0.27-4.63, p = 0.88) showed no significant differences. Cross-comparison demonstrated that IL-17 inhibitors had a higher risk of Candida infection compared to TNF-α inhibitors (OR = 2.23, 95% CI = 1.08-4.57, p = 0.03) and IL-12/23 inhibitors (OR = 4.21, 95% CI = 2.71-6.55, p < 0.00001). For dermatophyte infections, the overall risk associated with biologic agents was increased (OR = 1.89, 95% CI = 1.19-3.01, p = 0.007), IL-17 inhibitors showed a higher risk compared to IL-12/23 inhibitors (OR = 2.70 95% CI = 1.29-5.63, p = 0.008). Overall, biologic agents significantly increased the risk of superficial fungal infections compared to placebo (OR = 2.10, 95% CI = 1.73-2.55, p < 0.00001).

Conclusion: Biologic agents, particularly IL-17 inhibitors, notably increase the risk of superficial fungal infections in psoriasis patients. In clinical practice, targeted monitoring protocols should be established, including regular follow-up to promptly detect superficial fungal infections and initiate antifungal treatment as necessary.

Trial registration: PROSPERO: CRD42025636705.