Recent advances in biological therapies have proved highly effective in treating psoriasis and other inflammatory conditions, including psoriatic arthritis, rheumatoid arthritis, inflammatory bowel disease and ankylosing spondylitis. However, adverse effects related to their immunosuppression have been observed, including an increased propensity to viral infections. This review evaluates the evidence of herpes zoster (HZ) risk from biologics based on clinical reports, cohort studies and randomized controlled studies. The risk of HZ associated with these agents remains controversial, especially when comparing their risk with non-biological therapy used to treat the same inflammatory conditions. This review specifically assesses the risk of the TNF inhibitors etanercept, adalimumab and infliximab, as well as interleukin-12/23 inhibitor ustekinumab. We found multiple cohort studies, randomized controlled trials and case reports that suggest infliximab increases risk of HZ, whereas adalimumab, etanercept and ustekinumab HZ risk remain controversial. Nevertheless, HZ vaccination should be considered prior to initiation of biological therapy, particularly infliximab.

With the current landscape of phototherapy dominated by psoralen combined with ultraviolet A (PUVA) and narrow-band ultraviolet B (NB-UVB), an alternative light therapy utilizing the visible spectrum is certainly promising and a worthwhile endeavor to pursue.

With a growing understanding of the pathogenesis and immunological basis of psoriasis, the medical community has seen the development of more focused biological treatment options for patients suffering from the disease, which are beginning to revolutionize the treatment of psoriasis. It is already well known that certain biologics are associated with an increased risk of reactivating tuberculosis in patients with latent disease, however, with increasing use of biologic agents across indications, there has also been a rise in reports of associated deep fungal infections. The mechanism of action of these biologic anti-psoriatic therapies allows physicians to address the underlying cause of patients' symptoms. The question though, is whether this same therapeutic mechanism may predispose patients to serious infections, including deep fungal infections.

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