A Delphi Consensus on Tildrakizumab Dosing and Titration in Moderate-to-Severe Plaque Psoriasis
DOI:
https://doi.org/10.2340/actadv.v106.adv-2026-0593Keywords:
psoriasis, tildrakizumab, biologic therapy, personalized medicine, Delphi consensus, dose selectionAbstract
Tildrakizumab is approved for moderate-to-severe plaque psoriasis in 2 doses, 100 mg and 200 mg, with comparable safety profiles. This study aimed to establish pan-European consensus on optimal tildrakizumab dosing and titration using a modified Delphi methodology. A steering group of 8 European dermatologists developed 48 consensus statements addressing tildrakizumab prescribing, dose selection and titration. The statements were incorporated into an online Likert survey and distributed across 9 European countries to experienced dermatologists. Consensus was predefined as ≥75% agreement. Seventy-two dermatologists completed the survey. Consensus was achieved for 35/48 statements (73%). Based on the results, initiation with the 100 mg dose may be considered in patients weighing <90 kg with a body mass index <25, moderate disease severity or who are biologic-naïve. Initiation with the 200 mg dose may be considered in patients weighing ≥90 kg and/or with a body mass index ≥25, severe disease, high-impact area involvement in the context of severe disease, prior interleukin-23p19 inhibitor failure or failure of ≥2 biologics. Up-titration to 200 mg may be considered for suboptimal response, while down-titration to 100 mg may be considered after ≥1 year of sustained remission. Adoption of this guidance may facilitate more consistent, individualized dosing and improved patient outcomes.
Downloads
References
Reich K, Papp KA, Blauvelt A, Tyring SK, Sinclair R, Thaçi D, et al. Tildrakizumab versus placebo or etanercept for chronic plaque psoriasis (reSURFACE 1 and reSURFACE 2): results from two randomised controlled, phase 3 trials. Lancet 2017; 390: 276–288. DOI: https://doi.org/10.1016/S0140-6736(17)31279-5
Becher G, Conner S, Ingram JA, Stephen KE, McInnes AC, Heald AH, et al. A retrospective real-world study of the effectiveness and tolerability of tildrakizumab in UK adults with moderate-to-severe chronic plaque psoriasis. Dermatol Ther 2022; 12: 2343–2354. DOI: https://doi.org/10.1007/s13555-022-00800-3
Pinter A, Thaçi D, Sebastian M. Criteria for dose adjustment of tildrakizumab in psoriasis vulgaris. JEADV Clin Pract 2025; 4: 1225–1227. DOI: https://doi.org/10.1002/jvc2.70130
European Medicines Agency. Ilumetri. https://www.ema.europa.eu/en/medicines/human/EPAR/ilumetri
Di Brizzi EV, Caccavale S, Di Caprio R, Cusano F, De Pasquale R, Falcomatà V, et al. A prospective real-life multicenter study of tildrakizumab 200 mg in patients with moderate-severe psoriasis: who is the ideal patient? Dermatol Pract Concept 2024; 14: e2024284. DOI: https://doi.org/10.5826/dpc.1404a284
Trovato E, Bianchelli T, Odorici G, Cuccia A, Di Lernia VG, Lasagni C, et al. Effectiveness of tildrakizumab 200 mg in moderate-to-severe plaque psoriasis: a multicenter real-world study analyzing patient outcomes by weight, PASI, BMI, and previous therapies. Dermatol Ther 2025; 15: 1941–1952. DOI: https://doi.org/10.1007/s13555-025-01442-x
Dapavo P, Megna M, Talamonti M. Efficacy of tildrakizumab 200 mg for treating difficult-to-treat patient populations with moderate-to-severe plaque psoriasis. Dermatol Rep 2025; 17: 9999. DOI: https://doi.org/10.4081/dr.2024.9999
Valenti M, Ibba L, Di Giulio S, Gargiulo L, Malagoli P, Balato A, et al. Optimizing tildrakizumab dosing in psoriasis: a 52-week multicenter retrospective study comparing 100 mg and 200 mg—IL PSO (Italian Landscape Psoriasis). Dermatol Ther 2025; 15: 1427–1440. DOI: https://doi.org/10.1007/s13555-025-01416-z
Dattola A, Bernardini N, Svara F, Balato A, Caldarola G, D’Amico D, et al. Effectiveness of tildrakizumab 200 mg: an Italian multicenter study. J Dermatolog Treat 2024; 35: 2420825. DOI: https://doi.org/10.1080/09546634.2024.2420825
Nast A, Altenburg A, Augustin M, Bachmann F, Boehncke W, Cornberg M, et al. S3 Guideline for the treatment of psoriasis vulgaris, adapted from EuroGuiDerm – part 1: treatment recommendations and monitoring. J Deutsche Derma Gesell 2026; 24: 122–137. DOI: https://doi.org/10.1111/ddg.16002
Gisondi P, Fargnoli MC, Amerio P, Argenziano G, Bardazzi F, Bianchi L, et al. Italian adaptation of EuroGuiDerm guideline on the systemic treatment of chronic plaque psoriasis. Ital J Dermatol Venerol 2022; 157: 1–78. DOI: https://doi.org/10.23736/S2784-8671.21.07132-2
Nast A, Smith C, Spuls PI, Avila Valle G, Bata-Csörgö Z, Boonen H, et al. EuroGuiDerm Guideline on the systemic treatment of Psoriasis vulgaris - Part 1: treatment and monitoring recommendations. J Eur Acad Dermatol Venereol 2020; 34: 2461–2498. DOI: https://doi.org/10.1111/jdv.16915
Smith CH, Yiu ZZN, Bale T, Burden AD, Coates LC, Eckert E, et al. British Association of Dermatologists guidelines for biologic therapy for psoriasis 2023: a pragmatic update. Br J Dermatol 2024; 190: 270–272. DOI: https://doi.org/10.1093/bjd/ljad347
Ruiz-Villaverde R, Mateu A, Mendes-Bastos P, Torres T. Optimizing psoriasis treatment with tildrakizumab: current evidence and expert recommendations for treatment individualization in clinical practice. Dermatol Ther 2025; 15: 3071–3088. DOI: https://doi.org/10.1007/s13555-025-01538-4
Dapavo P, Burlando M, Guarneri C, Megna M, Narcisi A, Talamonti M, et al. Tildrakizumab: the value of a personalized and flexible approach for treating moderate-to-severe plaque psoriasis in patients with high body weight or high disease burden. Expert Opin Biol Ther 2024; 24: 133–138. DOI: https://doi.org/10.1080/14712598.2024.2325547
Niederberger M, Spranger J. Delphi technique in health sciences: a map. Front Public Health 2020; 8: 457. DOI: https://doi.org/10.3389/fpubh.2020.00457
Gattrell WT, Logullo P, van Zuuren EJ, Price A, Hughes EL, Blazey P, et al. ACCORD (ACcurate COnsensus Reporting Document): a reporting guideline for consensus methods in biomedicine developed via a modified Delphi. PLoS Med 2024; 21: e1004326. DOI: https://doi.org/10.1371/journal.pmed.1004326
Shang Z. Use of Delphi in health sciences research: a narrative review. Medicine 2023; 102: e32829. DOI: https://doi.org/10.1097/MD.0000000000032829
Diamond IR, Grant RC, Feldman BM, Pencharz PB, Ling SC, Moore AM, et al. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol 2014; 67: 401–409. DOI: https://doi.org/10.1016/j.jclinepi.2013.12.002
World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human participants. JAMA 2025; 333: 71–74. DOI: https://doi.org/10.1001/jama.2024.21972
Papp KA, Reich K, Blauvelt A, Kimball AB, Gooderham M, Tyring SK, et al. Efficacy of tildrakizumab for moderate-to-severe plaque psoriasis: pooled analysis of three randomized controlled trials at weeks 12 and 28. J Eur Acad Dermatol Venereol 2019; 33: 1098–1106. DOI: https://doi.org/10.1111/jdv.15400
Thaçi D, Gerdes S, Du Jardin KG, Perrot JL, Puig L. Efficacy of tildrakizumab across different body weights in moderate-to-severe psoriasis over 5 years: pooled analyses from the reSURFACE pivotal studies. Dermatol Ther 2022; 12: 2325–2341. DOI: https://doi.org/10.1007/s13555-022-00793-z
Gargiulo L, Ibba L, Cascio Ingurgio R, Malagoli P, Amoruso F, Balato A, et al. Comparative effectiveness of tildrakizumab 200 mg versus tildrakizumab 100 mg in psoriatic patients with high disease burden or above 90 kg of body weight: a 16-week multicenter retrospective study – IL PSO (Italian landscape psoriasis). J Dermatol Treat 2024; 35: 2350760. DOI: https://doi.org/10.1080/09546634.2024.2350760
Edson-Heredia E, Sterling KL, Alatorre CI, Cuyun Carter G, Paczkowski R, Zarotsky V, et al. Heterogeneity of response to biologic treatment: perspective for psoriasis. J Invest Dermatol 2014; 134: 18–23. DOI: https://doi.org/10.1038/jid.2013.326
Gebauer K, Spelman L, Yamauchi PS, Bagel J, Nishandar T, Crane M, et al. Efficacy and safety of tildrakizumab for the treatment of moderate-to-severe plaque psoriasis of the scalp: a multicenter, randomized, double-blind, placebo-controlled, Phase 3b study. J Am Acad Dermatol 2024; 91: 91–99. DOI: https://doi.org/10.1016/j.jaad.2024.03.025
Sofen HL, Gebauer K, Spelman L, Yamauchi PS, Yao SL, Nishandar T, et al. Efficacy and safety of tildrakizumab for the treatment of moderate-to-severe plaque psoriasis of the scalp: week 52 results from a phase 3b, randomized, double-blind, placebo-controlled trial. J Am Acad Dermatol 2025; 92: 816–824. DOI: https://doi.org/10.1016/j.jaad.2024.12.018
Diotallevi F, Esposito M, Fargnoli MC, Quaglino P, Mastorino L, Stingeni L, et al. Real-life experience with tildrakizumab in plaque psoriasis with palmoplantar involvement: a multi-center retrospective Italian study. Dermatol Ther 2025; 15: 323–336. DOI: https://doi.org/10.1007/s13555-025-01339-9
Galluzzo M, Talamonti M, Cioni A, Maffei V, Shumak RG, Tofani L, et al. Efficacy of tildrakizumab for the treatment of difficult-to-treat areas: scalp, nail, palmoplantar and genital psoriasis. JCM 2022; 11: 2631. DOI: https://doi.org/10.3390/jcm11092631
Burlando M, Maul JT, Salvi I, Simic D, Cozzani E, Ak M, et al. Psoriasis patients’ characteristics associated with high PASI response to tildrakizumab: an international dual center study. Eur Rev Med Pharmacol Sci 2022; 26: 6772–6776.
Melgosa Ramos FJ, Mateu Puchades A, Matáix-Díaz J, Schneller-Pavelescu L, Belinchón-Romero I, Santos Alarcón S. 52-week mid-term efficacy of tildrakizumab in moderate-to-severe psoriasis: a real-life multicenter experience. Actas Dermo-Sifiliográficas 2024; 115: 722–726. DOI: https://doi.org/10.1016/j.ad.2023.08.019
Burlando M, Castelli R, Cozzani E, Parodi A. Treatment of moderate-to-severe plaque psoriasis with tildrakizumab in the real-life setting. Drugs Context 2021; 10: 2021-2-6. DOI: https://doi.org/10.7573/dic.2021-2-6
Wei NW, Chi S, Lebwohl MG. Retrospective analysis in patients with moderate to severe plaque psoriasis treated with tildrakizumab: real-life clinical data. J Psoriasis Psoriatic Arthritis 2022; 7: 55–59. DOI: https://doi.org/10.1177/24755303221077211
Mastorino L, Cariti C, Susca S, Sciamarrelli N, Borriello S, Ortoncelli M, et al. Tildrakizumab in real-life shows good efficacy in moderate-to-severe psoriasis regardless of previous use of biologic drugs and joint involvement. Dermatol Ther 2022; 35: e15818. DOI: https://doi.org/10.1111/dth.15818
Ter Haar ELM, Van den Reek JMPA, Gaarn Du Jardin K, Barbero-Castillo A, De Jong EMGJ, Lubeek SFK. Efficacy and safety of tildrakizumab in older patients: pooled analyses of two randomized phase III clinical trials (reSURFACE 1 and reSURFACE 2) through 244 weeks. Acta Derm Venereol 2023; 103: adv17752. DOI: https://doi.org/10.2340/actadv.v103.17752
Lebwohl MG, Leonardi CL, Mehta NN, Gottlieb AB, Mendelsohn AM, Parno J, et al. Tildrakizumab efficacy, drug survival, and safety are comparable in patients with psoriasis with and without metabolic syndrome: Long-term results from 2 phase 3 randomized controlled studies (reSURFACE 1 and reSURFACE 2). J Am Acad Dermatol 2021; 84: 398–407. DOI: https://doi.org/10.1016/j.jaad.2020.09.047
Griss J, Ratzinger G, Maul JT, Weger W, Thaçi D, Carrascosa JM, et al. No impact of disease duration on response to tildrakizumab treatment among patients with moderate-to-severe plaque psoriasis: Post hoc analyses from two phase 3 (reSURFACE 1 and reSURFACE 2) and one phase 4 (TRIBUTE) studies. Skin Health Dis 2023; 3: e263. DOI: https://doi.org/10.1002/ski2.263
Griffiths CEM, Jo SJ, Naldi L, Romiti R, Guevara-Sangines E, Howe T, et al. A multidimensional assessment of the burden of psoriasis: results from a multinational dermatologist and patient survey. Br J Dermatol 2018; 179: 173–181. DOI: https://doi.org/10.1111/bjd.16332
Barbieri JS, Gelfand JM. Patient-reported outcome measures as complementary information to clinician-reported outcome measures in patients with psoriasis. JAMA Dermatol 2021; 157: 1236. DOI: https://doi.org/10.1001/jamadermatol.2021.3341
Carrascosa JM, Puig L, Belinchón Romero I, Salgado-Boquete L, Del Alcázar E, Andrés Lencina JJ, et al. Practical update of the recommendations published by the Psoriasis Group of the Spanish Academy of Dermatology and Venereology (GPS) on the treatment of psoriasis with biologic therapy. Part 1. Concepts and general management of psoriasis with biologic therapy. Actas Dermosifiliogr 2022; 113: 261–277. DOI: https://doi.org/10.1016/j.ad.2021.10.011
Torres T, Tavares Bello R, Paiva Lopes MJ, Menezes Brandão F, Ferreira A, Ferreira P, et al. Portuguese recommendations for the treatment of psoriasis with biologic therapy. Eur J Dermatol 2020; 30: 645–654. DOI: https://doi.org/10.1684/ejd.2020.3945
Additional Files
Published
How to Cite
License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All digitalized ActaDV contents is available freely online. The Society for Publication of Acta Dermato-Venereologica owns the copyright for all material published until volume 88 (2008) and as from volume 89 (2009) the journal has been published fully Open Access, meaning the authors retain copyright to their work.
Unless otherwise specified, all Open Access articles are published under CC-BY-NC licences, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for non-commercial purposes, provided proper attribution to the original work.
