Dermatology Online Journal

Letter: Long-term management of erythrodermic psoriasis with anti-TNF agents
Alberto Romero-Maté MD, Carmen García-Donoso MD, Cristina Martinez-Morán MD, Almudena Hernández-Núñez MD, Jesús Borbujo MD
Dermatology Online Journal 16 (6): 15

Department of Dermatology, Hospital de Fuenlabrada, Madrid, Spain. aromero.hflr@salud.madrid.org

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Abstract

Erythrodermic psoriasis is a chronic condition that is difficult to treat. Biological agents offer a new alternative, but there are no controlled trials to support their use; there are a few reports of patients treated with these agents, but often only with short term results. We report a 68-year-old man with erythrodermic psoriasis and ankylosing spondylitis, treated with infliximab for 48 weeks and then low-dose etanercept monotherapy for 34 additional months. Excellent results were obtained for both conditions without significant side effects. We think etanercept can be a good therapeutic option for long-term control of erythrodermic psoriasis.

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Introduction

Erythrodermic psoriasis is a therapeutic challenge. Cyclosporine and infliximab have a rapid onset of action and are recommended first line therapies; etanercept and methotrexate are considered second line agents, although in the case of etanercept, published data are very limited [1].

Case report

Figure 1
Figure 1. Patient in April 2006, erythroderma with big scales on the trunk

A 68-year-old patient with a 20-year history of psoriasis and an 18-year history of spondyloarthropathy presented in April 2006, with a flare of erythroderma involving approximately 100 percent of his body surface and a PASI of 65 (Figure 1). His first erythrodermic flare was 12 years prior and the frequency of flares had increased over the years. He had been treated in years past with acitretin and PUVA with good results, but relapses were frequent. The patient’s other medical comorbidities included hypertension and gout. His other medications included diltiazem, hydrochlorotiazide, cilazapril and allopurinol.

The diagnostic workup included complete blood cell count, biochemistry, anti-HIV antibodies, which were all within normal limits except for a serum urate of 8.1 mg/dl. A chest X-ray was normal and two PPD tests one week apart were negative. A skin biopsy was diagnostic of psoriasis.

In May 2006, treatment was initiated with infliximab 5 mg/kg at weeks 0, 2, and 6 and then every 8 weeks, during 48 weeks (8 infusions). He improved clearly by week 9 when his PASI dropped to 2; at week 20 the PASI score was 0. After the 6th infusion, infliximab lost efficacy and his psoriasis flared with large plaques on the trunk. Hence, at the end of the 48 week-period in April 2007, he had a PASI of 7, but with big and intense plaques on his back. We did not perform anti-infliximab antibodies. A new PPD test was positive, 11 mm, but he had no clinical symptoms suggesting active tuberculosis infection and a new chest X-ray was normal. Isoniazide, 300 mg daily, was initiated in April 2007 and maintained until January 2008; he did not develop any signs or symptoms of active tuberculosis for the next three years. In May 2007, with a PASI of 15, one month after isoniazide was started, etanercept 25 mg twice weekly was begun. The patient is currently continuing on this therapy.

Figure 2
Figure 2. Patient in January 2010, after more than 3.5 years of anti-TNF therapy, cleared of his psoriasis

During these 34 months, he had been essentially cleared of his psoriasis without remarkable side effects (Figure 2). He had two flares of erythroderma, in August 2007 and in October 2009. The first one could be managed by scaling the etanercept dose to 50 mg twice weekly for a 12-week period, with excellent response; the second flare required a 5-day hospitalization period, during which the same etanercept dose was maintained with the addition of topical steroids and coal tar baths. His disabling spondyloarthropathy, has been asymptomatic since the beginning of the anti-TNF therapy.

Discussion

Erythrodermic psoriasis is a therapeutic challenge and little is known about its response to biological agents; no large controlled-trials have been carried out. Infliximab has been used with good results in anecdotal reports, but the largest experiences are with only 5 [2] and 7 [3] patients. In the first series, two out of five patients achieved PASI 90 and another one PASI 75 [2]; in the second one, the seven patients experienced a 90 percent improvement after the third infusion [3]. None of the studies reported long-term results. Another report describes four patients, all with good results, treated with infliximab (2.7 to 4.4 mg/kg and infusions every 6-8 weeks), during a period of 5 years, 2 years, 1 year and 9 months respectively, associated with methotrexate (5 to 7.5 mg weekly), and in the last one, also with etanercept 25 mg twice weekly [4]. The first case series of etanercept-treated erythrodermic psoriasis, reported 10 patients treated with etanercept 25 mg twice weekly over a 24-week period; improvements were noted as early as week 12. PASI 75 was achieved by 60 percent and PASI 50 by 20 percent at the end of the study [5]. Another recently published case report describes a 69-year-old woman who achieved complete clearing with etanercept 50 mg twice weekly for 12 weeks followed by 25 mg twice weekly for 12 additional weeks [6].

We first used infliximab because of its rapid onset of action, but with successive infusions, it began to lose activity. We did not want to add methotrexate because of his previous history of hyperuricemia and gout. Therefore, we stopped infliximab and started etanercept, 25 mg twice weekly in May 2007. For the previous month he was progressively worsening because of the positive PPD test, the addition of isoniazide, and withholding of anti-TNF therapy. His PASI at the beginning of the etanercept course had worsened to 15, but he was not erythrodermic at that moment. The course since then has been satisfactory. The patient has a normal life without joint symptoms and he is free of psoriasis without any significant side effects. His two flares were easily controlled without a therapy switch or the addition of any other systemic agents. He has currently been on etanercept therapy for 34 months and anti-TNF therapy for a total of 46 months. To the best of our knowledge, we report the first patient with erythrodermic psoriasis successfully managed long-term with etanercept, without need of combined therapy with cyclosporine or methotrexate.

References

1. Rosenbach M, Hsu S, Korman NJ et al. Treatment of erythrodermic psoriasis: From the medical board of the National Psoriasis Foundation. J Am Acad Dermatol. 2010;62: 655-662. [PubMed]

2. Poulalhon N, Begon E, Lebbe C, et al. A follow-up study in 28 patients treated with infliximab for severe recalcitrant psoriasis: evidence for efficacy and high incidence of biological autoimmunity. Br J Dermatol 2007;156:329-36. [PubMed]

3. Takahashi MD, Castro LGM, Romiti R. Infliximab, as sole or combined therapy,induces rapid clearing of erythrodermic psoriasis. B J Dermatol 2007;157:828-31. [PubMed]

4. Heikkilä H, Ranki A, Cajanus S et al. Infliximab combined with methotrexate as long-term treatment for erythrodermic psoriasis. Arch Dermatol 2005;141:1607-10. [PubMed]

5. Esposito M, Mazzotta A. Treatment of erythrodermic psoriasis with etanercept. Br J Dermatol 2006;155:156-9. [PubMed]

6. Piqué-Duran E, Pérez-Cejudo J.A. Eritrodermia psoriásica tratada con etanercept. Actas Dermosifiliogr. 2007;98:506-12. [PubMed]

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