Biologicals are cutting edge molecules which have added to the armamentarium of the treating dermatologist. The biologicals/biosimilars available in India include TNF-a inhibitors, IL-17 inhibitors, T-cell Costimulatory blockers, B-cell depletion therapies like rituximab, IL-6R blockers (tocilizumab) and CD6 blocker (itolizumab). These molecules are currently approved in diseases like psoriasis, psoriatic arthritis, hidradenitis (TNFi all) and pemphigus and AAV (rituximab) among others. Off label indications of biologicals include pustular psoriasis, autoinflammatory diseases, subepidermal bullous disorders, connective tissue diseases, non-AAV vasculitis, neutrophilic dermatoses, lepra reactions and even severe syndromic follicular occlusion disorders like acne.

Practice sutra: The dermatologists must derive immunological insights about various innate and adaptive immune pathways and must use these agents judiciously for off label indications with risk benefit ratio assessment and adequate monitoring and screening.