Studies suggest that the complement pathway may play a role in the pathogenesis of idiopathic pulmonary fibrosis (IPF). We evaluated associations between complement pathway gene expression and clinical outcomes in patients with IPF. RNA was extracted from blood samples collected at enrollment into the IPF-PRO Registry. Patients were divided into discovery (n = 261) and validation (n = 609) cohorts. Patients were followed prospectively while receiving usual care. Using Cox proportional hazards models, we evaluated associations between expression of 45 complement pathway genes and three clinical outcomes. Analyses were unadjusted and adjusted for clinical variables at enrollment. Eight complement pathway genes (CR1, CD59, C2, C1QTNF6, ITGB3, C1QBP, CD55, CR2) were associated with ≥ 1 outcome in the discovery cohort and evaluated in the validation cohort. In the discovery cohort, in unadjusted analyses, higher expression of the membrane-bound complement regulators CR1, CD55, and CD59 was associated with increased risk (hazard ratios [HRs]: 1.75 [95

OBJECTIVE:We used data from the placebo arm of the Safety and Efficacy of Nintedanib in Systemic Sclerosis (SENSCIS) trial to determine the prognostic/predictive significance of peripheral blood cell (PBC) transcript modules for the course of forced vital capacity (FVC) in patients with systemic sclerosis-associated interstitial lung disease (SSc-ILD) with and without mycophenolate mofetil (MMF) treatment. METHODS:Patients had SSc-ILD with first non-Raynaud symptom within 7 years. MMF treatment was permitted if taken at a stable dose for ≥6 months. PBC RNA samples were taken at baseline. Global RNA sequencing was performed, followed by a modular analysis using 62 curated whole blood modules. The prognostic significance of baseline composite modular scores for decline in FVC% predicted at week 52 was analyzed using mixed models for repeated measures. RESULTS:Among patients taking MMF (n = 120), higher baseline lymphoid lineage and mitochondrial/protein synthesis modules were associated with a better course of FVC% predicted, whereas higher baseline myeloid lineage and inflammation modules were associated with a faster decline in FVC% predicted. Among patients not taking MMF (n = 118), only myeloid lineage and inflammation modules were associated with a faster decline in FVC% predicted. CONCLUSION:Among patients with SSc-ILD in the SENSCIS trial, PBC modules involved in myeloid lineage were associated with a faster decline in FVC regardless of MMF treatment. Higher baseline lymphoid, protein synthesis, and mitochondrial module scores were associated with a better course of SSc-ILD among patients receiving MMF treatment. Blood gene expression profiles might be useful prognostic/predictive biomarkers in patients with SSc-ILD.

We used data from the placebo arm of the Safety and Efficacy of Nintedanib in Systemic Sclerosis (SENSCIS) trial to determine the prognostic/predictive significance of peripheral blood cell (PBC) transcript modules for the course of forced vital capacity (FVC) in patients with systemic sclerosis-associated interstitial lung disease (SSc-ILD) with and without mycophenolate mofetil (MMF) treatment. Patients had SSc-ILD with first non-Raynaud symptom within 7 years. MMF treatment was permitted if taken at a stable dose for ≥6 months. PBC RNA samples were taken at baseline. Global RNA sequencing was performed, followed by a modular analysis using 62 curated whole blood modules. The prognostic significance of baseline composite modular scores for decline in FVC% predicted at week 52 was analyzed using mixed models for repeated measures. Among patients taking MMF (n = 120), higher baseline lymphoid lineage and mitochondrial/protein synthesis modules were associated with a better course of FVC% predicted, whereas higher baseline myeloid lineage and inflammation modules were associated with a faster decline in FVC% predicted. Among patients not taking MMF (n = 118), only myeloid lineage and inflammation modules were associated with a faster decline in FVC% predicted. Among patients with SSc-ILD in the SENSCIS trial, PBC modules involved in myeloid lineage were associated with a faster decline in FVC regardless of MMF treatment. Higher baseline lymphoid, protein synthesis, and mitochondrial module scores were associated with a better course of SSc-ILD among patients receiving MMF treatment. Blood gene expression profiles might be useful prognostic/predictive biomarkers in patients with SSc-ILD.

Segmental instillation of lipopolysaccharide (LPS) by bronchoscopy safely induces transient airway inflammation in human lungs. This model enables investigation of pulmonary inflammatory mechanisms as well as pharmacodynamic analysis of investigational drugs. The aim of this work was to describe the transcriptomic profile of human segmental LPS challenge with contextualization to major respiratory diseases. Pre-challenge bronchoalveolar lavage (BAL) fluid and biopsies were sampled from 28 smoking, healthy participants, followed by segmental instillation of LPS and saline as control. Twenty-four hours post instillation, BAL and biopsies were collected from challenged lung segments. Total RNA of cells from BAL and biopsy samples were sequenced and analysed for differentially expressed genes (DEGs). After challenge with LPS compared with saline, 6316 DEGs were upregulated and 241 were downregulated in BAL, but only one DEG was downregulated in biopsy samples. Upregulated DEGs in BAL were related to molecular functions such as “Inflammatory response” or “chemokine receptor activity”, and upregulated pro-inflammatory pathways such as “Wnt-"/“Ras-"/“JAK-STAT” “-signaling pathway”. Furthermore, the segmental LPS challenge model resembled aspects of the five most prevalent respiratory diseases chronic obstructive pulmonary disease (COPD), asthma, pneumonia, tuberculosis and lung cancer and featured similarities with acute exacerbations in COPD (AECOPD) and community-acquired pneumonia. Overall, our study provides extensive information about the transcriptomic profile from BAL cells and mucosal biopsies following LPS challenge in healthy smokers. It expands the knowledge about the LPS challenge model providing potential overlap with respiratory diseases in general and infection-triggered respiratory insults such as AECOPD in particular.

Background Idiopathic pulmonary fibrosis (IPF) is characterized by the accumulation of extracellular matrix in the pulmonary interstitium and progressive functional decline. We hypothesized that integration of multi-omics data would identify clinically meaningful molecular endotypes of IPF. Methods The IPF-PRO Registry is a prospective registry of patients with IPF. Proteomic and transcriptomic (including total RNA [toRNA] and microRNA [miRNA]) analyses were performed using blood collected at enrollment. Molecular data were integrated using Similarity Network Fusion, followed by unsupervised spectral clustering to identify molecular subtypes. Cox proportional hazards models tested the relationship between these subtypes and progression-free and transplant-free survival. The molecular subtypes were compared to risk groups based on a previously described 52-gene (toRNA expression) signature. Biological characteristics of the molecular subtypes were evaluated via linear regression differential expression and canonical pathways (Ingenuity Pathway Analysis [IPA]) over-representation analyses. Results Among 232 subjects, two molecular subtypes were identified. Subtype 1 (n = 105, 45.3%) and Subtype 2 (n = 127, 54.7%) had similar distributions of age (70.1 +/- 8.1 vs. 69.3 +/- 7.6 years; p = 0.31) and sex (79.1% vs. 70.1% males, p = 0.16). Subtype 1 had more severe disease based on composite physiologic index (CPI) (55.8 vs. 51.2; p = 0.002). After adjusting for CPI and antifibrotic treatment at enrollment, subtype 1 experienced shorter progression-free survival (HR 1.79, 95% CI 1.28,2.56; p = 0.0008) and similar transplant-free survival (HR 1.30, 95% CI 0.87,1.96; p = 0.20) as subtype 2. There was little agreement in the distribution of subjects to the molecular subtypes and the risk groups based on 52-gene signature (kappa = 0.04, 95% CI= -0.08, 0.17), and the 52-gene signature risk groups were associated with differences in transplant-free but not progression-free survival. Based on heatmaps and differential expression analyses, proteins and miRNAs (but not toRNA) contributed to classification of subjects to the molecular subtypes. The IPA showed enrichment in pulmonary fibrosis-relevant pathways, including mTOR, VEGF, PDGF, and B-cell receptor signaling. Conclusions Integration of transcriptomic and proteomic data from blood enabled identification of clinically meaningful molecular endotypes of IPF. If validated, these endotypes could facilitate identification of individuals likely to experience disease progression and enrichment of clinical trials. Trial registration NCT01915511

Background: Phase II trial data indicate that the preferential PDE4B inhibitor BI 1015550 prevents a decline in FVC over 12 weeks in patients with idiopathic pulmonary fibrosis (IPF). Aims and objectives: Using Phase II trial data, we investigated the effect of BI 1015550 on gene expression profiles and their association with FVC. Methods: 147 patients with IPF (77% male, mean FVC 77.7% predicted) who were receiving a stable dose of antifibrotic therapy (AF) or not receiving AF (non-AF) were randomised and treated with BI 1015550 (AF n=49; non-AF n=48) or placebo (AF n=25; non-AF n=25) for 12 weeks. Total RNA was isolated from peripheral blood. The effect of BI 1015550 on gene expression profiles and their association with change from baseline in FVC were analysed based on background AF. Results: There were no significant differences in gene expression profiles between treatment groups. However, in patients treated with BI 1015550 there were significant correlations between change in several fibrosis-linked genes and change in FVC over time in both the AF and non-AF groups; the most highly correlated genes differed between groups. These genes have not previously been linked to FVC change in IPF. Conclusions: These data are consistent with PDE4B inhibition acting primarily on the lung, with little effect seen on circulating inflammatory cells in patients with IPF.

Introduction: Idiopathic pulmonary fibrosis (IPF) is a fibrotic lung disease leading to loss of respiratory function. The IPF-PRO Registry is a prospective multi-centre registry that provides a valuable resource to investigate biomarkers associated with disease progression in patients with IPF. Aim: To develop a biomarker-inclusive model predictive of disease progression or death in patients with IPF. Methods: Using clinical data and blood samples taken from 558 patients with IPF at enrolment into the IPF-PRO Registry, we used a machine learning-based random forest survival approach to identify demographic/clinical parameters and gene and protein expression predictive of disease progression, i.e. a composite of drop in FVC % predicted >10%, lung transplant, or death. We utilized a feature pre-selection approach, based on univariable Cox regression models in conjunction with feature correlation, to maximize feature relevance and minimize redundancy among the biomarkers. Results: The final model for prediction of the composite endpoint included, among other parameters, DLCO % predicted, body mass index, SP-D protein expression, and MIXL1 gene expression. The combination of demographic/clinical parameters and gene or protein expression outperformed prediction of the composite endpoint based on demographic/clinical parameters only. We validated the model on a separate sub-cohort of 247 patients from the IPF-PRO Registry. Conclusions: The set of biomarkers identified in this analysis may serve as a panel to predict disease progression or death in patients with IPF.

Background: The IL-36 pathway plays a key role in the pathogenesis of generalized pustular psoriasis (GPP). In a proof-of-concept clinical trial, treatment with spesolimab, an anti-IL-36 receptor antibody, resulted in rapid skin and pustular clearance in patients presenting with GPP flares. Objective: We sought to compare the molecular profiles of lesional and nonlesional skin from patients with GPP or palmoplantar pustulosis (PPP) with skin from healthy volunteers, and to investigate the molecular changes after spesolimab treatment in the skin and blood of patients with GPP flares. Methods: Pre- and post-treatment skin and blood samples were collected from patients with GPP who participated in a single-arm, phase I study (n = 7). Skin biopsies from patients with PPP (n = 8) and healthy volunteers (n = 16) were obtained for comparison at baseline. Biomarkers were assessed by RNA-sequencing, histopathology, and immunohistochemistry. Results: In GPP and PPP lesions, 1287 transcripts were commonly upregulated or downregulated. Selected transcripts from the IL-36 signaling pathway were upregulated in untreated GPP and PPP lesions. In patients with GPP, IL-36 pathway-related signatures, T(H)1/T(H)17 and innate inflammation signaling, neutrophilic mediators, and keratinocyte-driven inflammation pathways were downregulated by spesolimab as early as week 1. Spesolimab also decreased related serum biomarkers and cell populations in the skin lesions from patients with GPP, including CD3(+) T, CD11c(+), and IL-36 gamma(+) cells and lipocalin-2-expressing cells. Conclusions: In patients with GPP, spesolimab showed rapid modulation of commonly dysregulated molecular pathways in GPP and PPP, which may be associated with improved clinical outcomes.

BACKGROUND:RORγt is a transcription factor that enables elaboration of Th17-associated cytokines (including IL-17 and IL-22) and is proposed as a pharmacological target for severe asthma.METHODS:IL-17 immunohistochemistry was performed in severe asthma bronchial biopsies (specificity confirmed with in situ hybridization). Primary human small airway epithelial cells in air liquid interface and primary bronchial smooth muscle cells were stimulated with recombinant human IL-17 and/or IL-22 and pro-inflammatory cytokines measured. Balb/c mice were challenged intratracheally with IL-17 and/or IL-22 and airway hyperreactivity, pro-inflammatory cytokines and airway neutrophilia measured. Balb/c mice were sensitized intraperitoneally and challenged intratracheally with house dust mite extract and the effect of either a RORγt inhibitor (BIX119) or an anti-IL-11 antibody assessed on airway hyperreactivity, pro-inflammatory cytokines and airway neutrophilia measured.RESULTS:We confirmed in severe asthma bronchial biopsies both the presence of IL-17-positive lymphocytes and that an IL-17 transcriptome profile in a severe asthma patient sub-population. Both IL-17 and IL-22 stimulated the release of pro-inflammatory cytokine and chemokine release from primary human lung cells and in mice. Furthermore, IL-22 in combination with IL-17, but neither alone, elicits airway hyperresponsiveness (AHR) in naïve mice. A RORγt inhibitor specifically blocked both IL-17 and IL-22, AHR and neutrophilia in a mouse house dust mite model unlike other registered or advanced pipeline modes of action. Full efficacy versus these parameters was associated with 90% inhibition of IL-17 and 50% inhibition of IL-22. In contrast, anti-IL-17 also blocked IL-17, but not IL-22, AHR or neutrophilia. Moreover, the deregulated genes in the lungs from these mice correlated well with deregulated genes from severe asthma biopsies suggesting that this model recapitulates significant severe asthma-relevant biology. Furthermore, these genes were reversed upon RORγt inhibition in the HDM model. Cell deconvolution suggested that the responsible cells were corticosteroid insensitive γδ-T-cells.CONCLUSION:These data strongly suggest that both IL-17 and IL-22 are required for Th2-low endotype associated biology and that a RORγt inhibitor may provide improved clinical benefit in a severe asthma sub-population of patients by blocking both IL-17 and IL-22 biology compared with blocking IL-17 alone.

Background: Short non-coding microRNAs (miRNAs) are involved in various cellular processes during disease progression of Crohn's disease (CD) and remarkably stable in feces, which make them attractive biomarker candidates for reflecting intestinal inflammatory processes. Here we investigated the potential of fecal miRNAs as noninvasive and translational CD biomarkers. Methods: MiRNAs were screened in feces of 52 patients with CD and 15 healthy controls using RNA sequencing and the results were confirmed by PCR. The relationship between fecal miRNA levels and the clinical CD activity index (CDAI) or CD endoscopic index of severity (CDEIS) was explored, respectively. Additionally, fecal miRNAs were investigated in dextran sodium sulfate, adoptive T-cell transfer, and Helicobacter typhlonius/stress-induced murine colitis models using the NanoString platform. Results: Nine miRNAs (miR-15a-5p, miR-16-5p, miR-128-3p, miR-142-5p, miR-24-3p, miR-27a-3p, miR-223-3p, miR-223-5p, and miR3074-5p) were significantly (adj. P < 0.05, >3-fold) increased whereas 8 miRNAs (miR-10a-5p, miR-10b-5p, miR-141-3p, miR-192-5p, miR200a-3p, miR-375, miR-378a-3p, and let-7g-5p) were significantly decreased in CD. MiR-192-5p, miR-375, and miR-141-3p correlated (P < 0.05) with both CDAI and CDEIS whereas miR-15a-5p correlated only with CDEIS. Deregulated expression of miR-223-3p, miR-16-5p, miR-15a-5p, miR-24-3p, and miR-200a-3p was also observed in murine models. The identified altered fecal miRNA levels reflect pathophysiological mechanisms in CD, such as Th1 and Th17 inflammation, autophagy, and fibrotic processes. Conclusions: Our translational study assessed global fecal miRNA changes of patients with CD and relevant preclinical models. These fecal miRNAs show promise as translational and clinically useful noninvasive biomarkers for mechanistic investigation of intestinal pathophysiology, including monitoring of disease progression.

Pustular psoriasis comprises a spectrum of inflammatory skin conditions, including GPP and PPP, characterized by neutrophilic infiltration of the epidermis and development of visible sterile pustules. GPP is a rare, multisystemic, potentially life-threatening, flaring disease, whereas PPP is a localized, relapsing, debilitating, chronic disease. Here, gene and protein expression of lesional and non-lesional skin from 7 patients with a moderate GPP flare, 8 patients with moderate-to-severe PPP, and skin samples from the thigh/back (n=10) or palm/sole (n=6) of healthy donors were compared. In lesional skin samples, 7,614 genes in GPP and 1,651 in PPP were found to be differentially expressed compared with healthy donors. In GPP and PPP, 1,287 transcripts were commonly up- or downregulated (adjusted p ≤0.01, absolute fold-change ≥2). Markedly upregulated genes in lesional vs non-lesional skin include IL36a, KRT6A, defensin4b, IL6, CXCL1, CXCL8, IL17A, IL23A, and IL1b; common molecular pathways included increased Th1 and Th17 signaling, keratinocyte-driven inflammation, and a strong upregulation of neutrophil attractants, inflammatory mediators, and the IL-36 pathway. Treatment of 7 GPP patients with a single 10 mg/kg IV dose of spesolimab (BI 655130; NCT02978690) led to rapid clinical improvements and modulation of the transcriptomic profile and select proteins in the skin (NE and lipocalin 2) and blood (IL-6, CRP, CXCL1, IL1RN, CCL20) common to GPP and PPP.

Background: Limited data are available on phenotypes of idiopathic pulmonary fibrosis (IPF). Aim: To identify molecular-based IPF subtypes using integrative clustering models based on proteomics and transcriptomics data. Methods: Proteomics, miRNA and total RNAseq data from blood samples taken from 243 patients in the multicenter observational IPF-PRO Registry were analyzed. iClusterPlus, iClusterBayes and Similarity Network Fusion (SNF) models were applied for integrative analyses. Composite physiologic index (CPI); GAP stage; diagnostic criteria; DLco, FEV1 and FVC % predicted at baseline; and time to death, lung transplant or FVC decline >10% predicted were compared between the clusters. Pathway analyses were performed using Enrichr. Results: There was large overlap in cluster memberships across the models. There were significant differences in mean CPI, DLco % predicted and FVC % predicted at baseline, and in time to death, lung transplant or FVC decline >10% predicted between clusters identified using the SNF model (Figure). Pathways analysis of the most discriminative genes and proteins revealed enrichment for terms related to the immune system. Conclusion: Integrative multi-omics clustering analysis identified distinct molecular-based IPF phenotypes that differed in measures of disease severity and disease progression.

MicroRNAs (miRNAs) are short, non-coding RNA species that are important post-transcriptional regulators of gene expression and play an important role in the pathogenesis of non-alcoholic fatty liver disease. Here, we investigated the phosphodiesterase 5 (PDE5) inhibitor induced effects on hepatic and plasma exosomal miRNA expression in CCl4-treated rats. In the present study, hepatic miRNA profiling was conducted using the Nanostring nCounter technology and mRNA profiling using RNA sequencing from PDE5 treated rats in the model of CCl4-induced liver fibrosis. To evaluate if the PDE5 inhibitor affected differentially expressed miRNAs in the liver can be detected in plasma exosomes, qRT-PCR specific assays were used. In livers from CCl4-treated rats, the expression of 22 miRNAs was significantly increased (>1.5-fold, adj. p < 0.05), whereas the expression of 16 miRNAs was significantly decreased (>1.5-fold, adj. p < 0.05). The majority of the deregulated miRNA species are implicated in fibrotic and inflammatory processes. The PDE5 inhibitor suppressed the induction of pro-fibrotic miRNAs, such as miR-99b miR-100 and miR-199a-5p, and restored levels of anti-fibrotic miR-122 and miR-192 in the liver. In plasma exosomes, we observed elevated levels of miR-99b, miR-100 and miR-142-3p after treatment with the PDE5-inhibitor compared to CCl4/Vehicle-treated. Our study demonstrated for the first time that during the development of hepatic fibrosis in the preclinical model of CCl4-induced liver fibrosis, defined aspects of miRNA regulated liver pathogenesis are influenced by PDE5 treatment. In conclusion, miRNA profiling of plasma exosomes might be used as a biomarker for NASH progression and monitoring of treatment effects.

INTRODUCTION:LUME-Colon 1 (NCT02149108) was a global, placebo-controlled phase III study of nintedanib in advanced colorectal cancer (CRC). Pre-specified biomarker analyses investigated the association of CRC consensus molecular subtypes (CMS) and tumor genomic and circulating biomarkers with clinical outcomes. MATERIALS AND METHODS:Archival tumor tissue, cell-free DNA (cfDNA), and plasma samples were collected for genomic, transcriptomic, and proteomic analyses to investigate potential associations between CRC CMS and other biomarkers with nintedanib response and clinical outcomes. RESULTS:Of the 765 treated patients, 735, 245, and 192 patient samples were analyzed in the circulating protein, tumor tissue, and cfDNA datasets, respectively. Patients were classified as CMS1 (1.7%), CMS2 (27.7%), CMS3 (0.9%), CMS4 (51.5%), or unclassified (18.2%). Unclassified/mixed CMS was associated with longer overall survival (OS) with nintedanib vs. CMS2 or CMS4 (interaction P-value = .0086); no association was observed for CMS4. Gene expression-based pathway analysis revealed an association between vascular endothelial growth factor-related signaling and OS for nintedanib (P = .0498). The most frequently detected somatic mutations were APC (72.0% [tumor tissue] vs. 56.8% [cfDNA]), TP53 (47.1% vs. 34.9%), KRAS (40.8% vs. 28.6%), and PIK3CA (16.6% vs. 11.5%); concordance rates were > 80%. Median OS differences were observed for APC and TP53 mutations vs. wild-type in cfDNA, indicating a potential prognostic value. Circulating ANG-2, CA-9, CEACAM1, collagen-IV, IGFBP-1, ICAM-1, IL-8, and uPAR were potentially prognostic for both OS and progression-free survival. CONCLUSION:We demonstrated the feasibility of large-scale biomarker analyses and CMS classification within a global clinical trial, and identified signals suggesting a potential for greater nintedanib treatment response in the unclassified/mixed CMS subgroup, despite these tumors showing heterogeneous patterns of CMS mixtures. Our results revealed a high degree of concordance in somatic mutations between tumor tissue and cfDNA. Associations with prognosis for cfDNA somatic mutations, as well as several protein-based biomarkers, may warrant further investigation in future trials.

Generalized pustular psoriasis (GPP) is a rare, life-threatening disease, characterised by recurrent flares of pustular, erythematous rashes, with a strong genetic linkage to the IL-36 pathway. The efficacy and safety of a single, open-label, intravenous dose of spesolimab (BI 655130; 10 mg/kg), an anti-IL-36R monoclonal antibody, was assessed in a Phase I trial (NCT02978690) in 7 patients presenting with a moderate-to-severe GPP flare. To characterise the molecular response to spesolimab, biomarkers in lesional skin and blood were analysed. Spesolimab treatment resulted in all patients achieving a GPP Physician Global Assessment (GPPGA) score of 0 or 1 by Week 4. In lesional skin, improvement in GPPGA score was accompanied by a strong downregulation of genes associated with the IL-36 family (IL36G, IL36A), innate immune response (TNF, IL1B, IL6), Th1/Th17-mediated inflammation (IL12B, IL23, IL17C, IL22) and neutrophil attractant pathways (CXCL1/2/3/5/6/8, NCF1/2/4, ELANE). In blood, pro-inflammatory genes involved in neutrophil activation (IL1B, CD177, S100A8/9, S100A12, MMP9, MMP25) were strongly downregulated after spesolimab treatment; these changes were accompanied by reductions in blood protein expression (IL-6, CRP, CXCL1, IL1RN, CCL20). mRNA and protein reduction were observed as early as Day 7 after spesolimab treatment and maintained through Week 4. Overall, in addition to clinical improvements, inhibition of IL-36R with spesolimab was associated with strong downregulation of neutrophil-focused pathogenic pathways in lesional skin and blood of GPP patients.

Background: IL-23 contributes to the activation, maintenance, and proliferation of TH17 cells and plays a major role in psoriasis pathophysiology. IL-23p19 inhibition with risankizumab resulted in superior clinical responses in patients with psoriasis compared with ustekinumab (dual IL-12/IL-23 inhibitor), but comparative molecular effects have not been established. Objective: We investigated the similarities and differences in molecular and histopathologic profiles in skin lesions from patients with psoriasis receiving risankizumab versus ustekinumab at an early time point. Methods: Lesional skin biopsy samples from 81 patients with moderate-to-severe plaque psoriasis participating in 2 different studies (a phase I risankizumab study and a phase II study of risankizumab vs ustekinumab) were analyzed by using histopathology, immunohistochemistry, and RNA sequencing. Results: Risankizumab induced a rapid decrease in levels of proteins and transcriptomic biomarkers associated with the IL-23 pathway, which were maintained through 8 weeks. At week 4, risankizumab decreased histopathologic expression of biomarkers, including K16, Ki67, CD3, lipocalin-2, CD11c, dendritic cell lysosome-associated membrane glycoprotein, beta-defensin 2, and S100A7; global histopathologic scoring revealed that 54% and 69% of patients treated with 90 or 180 mg of risankizumab, respectively, were graded as experiencing "excellent improvement'' versus 29% of patients treated with ustekinumab. At week 4, there was a common decrease in expression of 2645 genes expressed in lesional skin between patients receiving risankizumab and ustekinumab and a significant decrease in 2682 genes unique to risankizumab treatment. Risankizumab more strongly downregulated expression of genes associated with keratinocytes, epidermal cells, and monocytes, versus ustekinumab. Conclusion: Risankizumab demonstrated more pronounced changes in the molecular and histopathologic profile of psoriatic skin lesions compared with ustekinumab at week 4.