Erythrodermic Psoriasis Treated with Golimumab: A Case Report

Current and emerging prospects in the psoriatic treatment

Psoriasis is an autoimmune chronic disorder that causes inflammation and a scaly epidermis. The exact pathogenesis of the disease is not known yet. According to the studies, psoriasis is considered an immune-mediated disease. Until now it is believed that genetic and environmental factors are responsible for the disease. There are many comorbidities associated with psoriasis which increases difficulties as patients in some cases get addicted to drugs, alcohol, and smoking which reduces their quality of life. The patient may face social ignorance or suicidal thoughts which may arise in the patient's mind. Due to the undefined trigger of the disease, the treatment is not fully established but by considering the severe impact of the disease researchers are focusing on novel approaches for successful treatment. which has succeeded to a large extent. Here we review pathogenesis, problems faced by psoriatic patients, the need for the development of new treatments over conventional therapies, and the history of psoriatic treatments. We thoroughly focus on emerging treatments like biologics, biosimilars, and small molecules which are now showing more efficacy and safety than conventional treatments. Also, this review article discusses novel approaches which are now in research such as drug repurposing, treatment by stimulation of the vagus nerve, regulation of microbiota, and autophagy for improving disease conditions.

Biological treatment for erythrodermic psoriasis

INTRODUCTION

Erythrodermic psoriasis (EP) is an extreme and potentially life-threatening form of psoriasis in which most or all of the body surface area is affected by psoriasis. It occurs in 1-2% of patients with psoriasis and is less responsive to conventional therapies. Biologics have shown promise in the management of EP.

AREAS COVERED

This review briefly discusses the pathophysiology of EP. Current evidence on established and emerging targeted therapies for EP is covered, including anti-TNF-α biologics, IL-12/23, IL-17, and IL-23 inhibitors.

EXPERT OPINION

The need for rapidly acting, safe, and efficacious agents in EP has been met with advent of newer biologics, particularly IL-17 and IL-23 inhibitors. These targeted approaches warrant consideration as first-line management option for the management of EP; however, high-quality evidence regarding their long-term efficacy and safety in EP is lacking. Novel biologics such as bimekizumab and mirikizumab, and nanobodies such as netakimab and sonelokimab have shown promise in the management of plaque psoriasis, and potential of these molecules in management of EP should be explored. Management of patients with prior biologic failure remains a challenge. Guidelines for the management of EP need to be revisited in light of the recent advances.

MGATRx: Discovering Drug Repositioning Candidates Using Multi-View Graph Attention

In-silico drug repositioning or predicting new indications for approved or late-stage clinical trial drugs is a resourceful and time-efficient strategy in drug discovery. However, inferring novel candidate drugs for a disease is challenging, given the heterogeneity and sparseness of the underlying biological entities and their relationships (e.g., disease/drug annotations). By integrating drug-centric and disease-centric annotations as multi-views, we propose a multi-view graph attention network for indication discovery (MGATRx). Unlike most current similarity-based methods, we employ graph attention network on the heterogeneous drug and disease data to learn the representation of nodes and identify associations. MGATRx outperformed four other state-of-art methods used for computational drug repositioning. Further, several of our predicted novel indications are either currently investigated or are supported by literature evidence, demonstrating the overall translational utility of MGATRx.

Two cases of Erythrodermic psoriasis treated with Golimumab

Introduction and importance

Erythrodermic psoriasis (EP) is a very severe subtype of psoriasis, with a challenge poses in its treatment, as currently available therapies often provide unsatisfactory results, for those many biologics have been used in the treatment of EP such as Golimumab which has been extensively studied for the treatment of psoriatic arthritis, and chronic plaque psoriasis. However, no clinical trials have been performed for EP.

Case presentation

We report two cases of a 23-year old female, and a 31-year male who presented with severe psoriasis that previously un respond to ultraviolet B phototherapy, methotrexate, cyclosporine, and topical agents. Skin lesions worsened progressively and developed into erythroderma. Therefore, we administered golimumab 50 mg, which lead to the improvement of the skin lesions according to the Psoriasis Area and Severity Index score after the first administration; lesions improved further throughout the treatment course.

Conclusion

Golimumab may be an alternative treatment for Erythrodermic psoriasis patients unrespond to other treatments even it did not have the FDA approval, so this is an off label indication and treatment.

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Erythrodermic psoriasis is a very severe subtype of psoriasis, with a challenge poses in its treatment.

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Golimumab is tumor necrosis factor inhibitors.

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Golimumab is FDA approved treatment for psoriatic arthritis, and chronic plaque psoriasis. However, no clinical trials have been performed for the treatment of erythrodermic psoriasis.

Erythrodermic Psoriasis and Staph-Infective Endocarditis—A Conundrum in Succession

Erythrodermic psoriasis is a rare subtype of psoriasis vulgaris that presents with diffuse erythema and desquamation over greater than 75% of the body’s surface area. We present a case of a 57-year-old male who was admitted with a diffuse, erythematous scaly rash covering his entire body, with associated subjective fevers. Skin biopsy revealed erythrodermic psoriasis, and blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Echocardiogram revealed a mitral valve vegetation. Clinical improvement was achieved with intravenous antibiotic administration and topical corticosteroids without the use of immunomodulators.

Updates on the Treatment of Erythrodermic Psoriasis

Erythrodermic psoriasis (EP) is a rare variant of psoriasis, which is potentially life threatening and often resistant to conventional therapy. Biologics have revolutionized the treatment of plaque-type psoriasis, and shown promise in EP. However, due to the lack of head-to-head studies and the rarity of EP, no high level evidence-based treatment guidelines for EP have been established, and the evidence of treatment of EP is limited to case reports or small case series. Here, we present a narrative review focusing on the up-to-date information for the treatment of EP.

Targeted Treatment for Erythrodermic Psoriasis: Rationale and Recent Advances

Erythrodermic psoriasis (EP) is an extreme and often refractory variant of psoriasis with high morbidity and increased mortality, and is frequently classified as a dermatological emergency. The pathophysiology of EP is largely unknown but is thought to differ from that of plaque psoriasis. Treatment of EP is challenging, and usually based on clinical experience and patient co-morbidities, due to its low incidence and limited clinical evidence. Conventional treatments, such as topical glucocorticoid therapy, cyclosporin, acitretin, and methotrexate have some but limited efficacy in EP, and treatment discontinuation may result in flares. Newer biological drugs, including anti-TNF, anti-IL-17, and anti-IL-12/23 agents, have shown promise in therapeutic management of EP, but most of the available evidence is currently based on small case series and reports. Few studies have compared available treatment options for EP, and further clinical studies are necessary to provide clinical data and optimal treatment guidelines for EP patients. Here, we provide a comprehensive review of the background of EP, assess the available clinical data on the efficacy of targeted therapies, and aim to provide a foundation for clinical decision making for this rare form of psoriasis.

The Use of TNFα Inhibitors in Treating Pediatric Skin Disorders

Tumor necrosis factor alpha (TNF) inhibitors have had a significant impact in medicine since the approval of the first drug of its class by the US FDA in 1998. New clinical data and indications have emerged for TNF inhibitors in recent years. Currently, four TNF inhibitors have been approved by the US FDA for dermatology, two of which include US FDA-approved pediatric use. In particular, growing evidence supports the use of etanercept and adalimumab as attractive therapies for pediatric psoriasis. Data for use of etanercept in treating toxic epidermal necrolysis and either etanercept or infliximab for Kawasaki disease is expanding. In addition, there have been clinical reports on the use of TNF inhibitors to treat a variety of other pediatric dermatologic conditions. To help clinicians keep pace with the new data provided by many pediatric dermatology studies involving TNF inhibitors, this review provides an overview of the use of TNF inhibitors in the treatment of pediatric plaque psoriasis, hidradenitis suppurativa, atopic dermatitis, pyoderma gangrenosum, toxic epidermal necrolysis, and Kawasaki disease. For TNF inhibitors with little data in the pediatric population, data on adult use is discussed. Furthermore, the review summarizes available clinical data on efficacy, safety, and tolerability of agents currently available.

Complete resolution of erythrodermic psoriasis with first-line apremilast monotherapy

Erythrodermic psoriasis (EP) is the most serious type of psoriasis with high morbidity and mortality. First-line recommended therapies for EP, cyclosporine and infliximab have significant adverse effects. Cyclosporine increases the risk of hypertension, leucopenia, infections and renal failure. Infliximab increases the risk of reactivation of tuberculosis, hepatitis B and histoplasmosis, and increases risk for hepatitis, autoantibody formation, congestive heart failure, demyelinating disorders, pancytopenia, lymphoma and skin cancer. An effective drug with a much safer side effect profile will be of significant benefit in EP. The phosphodiesterase 4 inhibitor apremilast is U.S Food and Drug Administration (FDA) approved for plaque psoriasis and psoriatic arthritis. Adverse effects of apremilast reported are headache, nausea, diarrhoea, upper respiratory tract infection, potential for depression and weight loss. We report complete and long-standing resolution of EP with first-line apremilast monotherapy. Apremilast may be an effective option with comparatively minor side effects for EP.

Erythrodermic Psoriasis Treated with Apremilast

Erythroderma is a rare potentially deadly exfoliative dermatitis characterized by diffuse cutaneous erythema which may be associated with multi-organ dysfunction. Therefore, it is imperative to recognize and treat it promptly. Erythrodermic psoriasis is the most common form of erythroderma. Management of this condition is largely based on aggressive supportive care and the use of anti-inflammatory immunosuppressive and biologic agents. We describe a case of psoriatic erythroderma which was triggered by withdrawal from systemic steroids and successfully treated with apremilast and cyclosporine. Apremilast induced atrial fibrillation limited its continued use after the initial response period.

Erythrodermic psoriasis: pathophysiology and current treatment perspectives

Erythrodermic psoriasis (EP) is a rare and severe variant of psoriasis vulgaris, with an estimated prevalence of 1%-2.25% among psoriatic patients. The condition presents with distinct histopathologic and clinical findings, which include a generalized inflammatory erythema involving at least 75% of the body surface area. The pathogenesis of EP is not well understood; however, several studies suggest that the disease is associated with a predominantly T helper 2 (Th2) phenotype. Given the morbidity and potential mortality associated with the condition, there is a need for a better understanding of its pathophysiology. The management of EP begins with a comprehensive assessment of the patient's presentation and often requires multidisciplinary supportive measures. In 2010, the medical board of the US National Psoriasis Foundation published consensus guidelines advocating the use of cyclosporine or infliximab as first-line therapy in unstable cases, with acitretin and methotrexate reserved for more stable cases. Since the time of that publication, additional information regarding the efficacy of newer agents has emerged. We review the latest data with regard to the treatment of EP, which includes biologic therapies such as ustekinumab and ixekizumab.