Researchers Report 2 Cases of Erythrodermic Psoriasis Effectively Treated With Secukinumab

Researchers in China documented 2 cases of refractory erythrodermic psoriasis (EP) effectively treated with secukinumab, a fully humanized immunoglobulin (IgG)1k monoclonal antibody that neutralizes interleukin (IL)-17A. After 4 weeks of a standard treatment regimen, patients demonstrated a 75% reduction in the Psoriasis Area and Severity Index score (PASI).

Although secukinumab has been shown to result in rapid and sustained improvements of plaque psoriasis symptoms, clinical data on the treatment of EP with the drug are scarce. The condition, which accounts for 1% to 2.25% of all psoriatic cases, impacts over 80% of the body surface area (BSA) and usually occurs in patients with poor control of existing psoriasis.

Both patients included in the case series (1 male, 1 female) presented with severe EP and were resistant to treatment with acitretin or methotrexate. The male patient also presented with cirrhosis while the female patient had iridocyclitis. Both individuals continued with secukinumab for at least 32 weeks and no adverse reactions were observed during follow-up.

The 50-year-old female patient originally presented with plaque psoriasis lesions at age 26. “Her erythroderma was initially relieved under oral acitretin but soon gradually thickened and spread to the whole body,” authors wrote. In July of 2019 she presented to a dermatology clinic with extensive erythroderma (100% BSA) and a PASI score of 40.

Following once weekly treatment of 300 mg of secukinumab subcutaneously between weeks 0 through 4, and 300 mg every 4 weeks, the patient’s PASI score and BSA decreased to 9.8% and 40.45%, respectively, at week 4. By week 12, she achieved a 90% reduction in PASI score with no adverse events, while at 32 weeks she remained free of relapse and adverse events.

Similarly, a 46-year-old man who was diagnosed with plaque psoriasis during adolescence achieved initial alleviation using oral acitretin treatment at age 38. In May 2019, the drug exhibited decreased efficacy and the patient was admitted in July 2019 with extensive erythroderma (PASI 28, BSA 80%). The patient also exhibited signs of early cirrhosis caused by the drug and other factors, though tests revealed normal liver and kidney function.

At weeks 0,1,2,3, and 4 the male patient injected 300 mg of secukinumab, followed by a 300 mg dose once every 4 weeks. At week 4, the patient’s PASI score and BSA decreased to 7.6 and 29.6%, respectively. Results were sustained without any side effects after 40 weeks.

National Psoriasis Foundation guidelines, updated in 2010, recommend cyclosporine or infliximab as first-line therapy for unstable cases of EP and acitretin or methotrexate for patients who present with less acute disease.

“However, traditional treatments, including acitretin, cyclosporine, methotrexate, and supportive symptomatic treatment, often have limited efficacy and adverse effects, which do not meet the expectations of patients,” authors wrote.

Because patients in China typically use traditional Chinese medicine for initial treatment, individuals have often already developed moderate or severe psoriasis by the time they seek professional help.

“As noted with other biologic drugs, the metabolism of secukinumab is not affected by renal function, and hemodialysis does not seem to affect its plasma concentration,” researchers said.

Future clinical trials with large samples ought to be carried out to support findings while personalized plans based on patient characteristics to ensure retention rates and reduce adverse reactions are warranted.

Secukinumab may be a viable, rapid treatment option for patients with EP who experience failure of multiple therapies, authors concluded.

Reference

Liu L, Jin X, Sun C, and Xia J. two cases of refractory erythrodermic psoriasis effectively treated with secukinumab and a review of the literature. Dermatol Ther. Published online February 2, 2021. doi:10.1111/dth.14825