Biologic treatments for palmoplantar psoriasis and palmoplantar pustulosis: a systematic review and network meta-analysis.

The treatment of palmoplantar psoriasis (PPP), manifesting as hyperkeratotic plaques or pustular lesions (palmoplantar pustulosis -PPPP), is challenging. We aimed to evaluate the efficacy of various biologic treatments for PPP through a network meta-analysis. Systematic review and network meta-analysis of randomized controlled trials (RCTs) involving biologic treatments for adult patients with PPP or PPPP. Databases searched included PubMed, Embase, CENTRAL, Scopus, and trial registries (ClinicalTrials.gov, WHO ICTRP). The search was conducted from inception to May 2026. Studies comparing biologic agents were included. The primary outcome was the proportion of patients achieving ppPASI75 or equivalent PGA 0/1 at week 14-16. A Bayesian random-effects network meta-analysis was performed, reporting 95% credible intervals (CrI). 20 RCTs with 2,158 patients were included. Significant efficacy was observed for adalimumab (OR: 6.8, 95% CrI: 1.5-31), guselkumab 100 mg (OR: 7.4, 95% CrI: 2.0-2), ixekizumab (OR: 10.0, 95% CrI: 2.2-44), and secukinumab (OR: 6.1, 95% CrI: 1.7-27) compared to placebo. SUCRA values were highest for ixekizumab (87.2%), guselkumab 100 mg (84.1%), adalimumab (76.5%), and secukinumab (71.3%). Patients with exclusive palmoplantar involvement had a more challenging response to treatment. Biologic therapies offer significant improvement in managing PPP and PPPP. Specific biologic agents showed superior efficacy, allowing optimization of treatment strategies; however, these findings are based on indirect comparisons and heterogeneous populations, and should therefore be interpreted with caution. Future research should focus on direct comparisons, phenotype-specific trials, and long-term efficacy to enhance patient outcomes and quality of life.