biologic agents offer a range of new therapeutic options for patients with psoriasis however the relative benefit risk profiles of such therapies are not well known we compared two biologic agents ustekinumab an interleukin 12 and interleukin 23 blocker and etanercept an inhibitor of tumor necrosis factor alpha for the treatment of psoriasis we randomly assigned 903 patients with moderate to severe psoriasis to receive subcutaneous injections of either 45 or 90 mg of ustekinumab at weeks 0 and 4 or high dose etanercept 50 mg twice weekly for 12 weeks the primary end point was the proportion of patients with at least 75 improvement in the psoriasis area and severity index pasi at week 12 a secondary end point was the proportion with cleared or minimal disease on the basis of the physician s global assessment assessors were unaware of the treatment assignments the efficacy and safety of a crossover from etanercept to ustekinumab were evaluated after week 12 there was at least 75 improvement in the pasi at week 12 in 67 5 of patients who received 45 mg of ustekinumab and 73 8 of patients who received 90 mg as compared with 56 8 of those who received etanercept p 0 01 and p 0 001 respectively similarly 65 1 of patients who received 45 mg of ustekinumab and 70 6 of patients who received 90 mg of ustekinumab had cleared or minimal disease according to the physician s global assessment as compared with 49 0 of those who received etanercept p 0 001 for both comparisons among patients who did not have a response to etanercept 48 9 had at least 75 improvement in the pasi within 12 weeks after crossover to ustekinumab one or more adverse events occurred through week 12 in 66 0 of patients who received 45 mg of ustekinumab and 69 2 of patients who received 90 mg of ustekinumab and in 70 0 who received etanercept 1 9 1 2 and 1 2 respectively had serious adverse events safety patterns were similar before and after crossover from etanercept to ustekinumab the efficacy of ustekinumab at a dose of 45 or 90 mg was superior to that of high dose etanercept over a 12 week period in patients with psoriasis clinicaltrials gov number nct00454584.