New Recommendations for Erythrodermic, Pustular Psoriasis

| Melissa Leavitt

A recent study offers new recommendations for treating severe forms of psoriasis.

Pustular and erythrodermic psoriasis are both dangerous conditions that can pose serious health risks. Yet people with these forms of psoriasis can face limited treatment options. In an effort to identify a better alternative, a group of researchers reviewed past studies examining the use of biologics for these patients.

Their findings, published in the Journal of Drugs in Dermatology, suggest that biologics can be an effective treatment option for pustular and erythrodermic psoriasis, particularly during an emergency flare.

Currently, many people with these forms of psoriasis take systemic medications such as cyclosporine or Soriatane (acitretin), which affect the entire immune system. "But only one systemic medication, cyclosporine, is fast-acting enough to be used in an emergency, and not everyone responds to that," said Dr. Ethan Levin, the lead author of the study. In addition, the traditional oral therapies can have severe side effects.

This study investigated whether biologics, which target specific parts of the immune system, could be a better option for patients who do not respond well to systemics. The use of biologics for these specific conditions has not been extensively studied.

"Patients with these forms of psoriasis may be frustrated, because there is a lack of evidence regarding treatment options," said Dr. Wilson Liao, senior author of the study.

"There is extensive data on chronic plaque psoriasis, but erythrodermic and pustular psoriasis are excluded from clinical trials," explained Levin. "We wanted to see if we could point toward something more evidence-based."

Researchers reviewed 45 past studies testing the use of biologics for these forms of psoriasis. In the cases they reviewed, Remicade (infliximab), Humira (adalimumab), Enbrel (etanercept) and Stelara (ustekinumab) were used to treat both kinds of psoriasis. Kineret (anakinra), a biologic medication for rheumatoid arthritis, was used to treat two cases of pustular psoriasis.

Serious side effects occurred in 10 percent of patients with pustular psoriasis, and 12 percent of patients with erythrodermic psoriasis. Most of these side effects were infections, which can become life- threatening in both forms of psoriasis. Side effects in cases of erythrodermic psoriasis also included one heart attack, one case of lymphoma, and one death (although, the article notes, the cause of death was never determined).

Based on their findings, the researchers offer clinical guidelines for treating these conditions.

"If it is an acute, severe flare that requires hospitalization, we would suggest using a fast-acting medication like Remicade or cyclosporine," said Liao. "For sub-acute or low-grade cases, we would recommend trying Enbrel, Humira, Stelara or Soriatane."

They also point out the need for further research in this area."

Most of the published data is retrospective," noted Levin. "We need prospective studies that test biologic medications against a placebo or against another type of treatment."

The researchers recommend that people with severe forms of psoriasis find a doctor who can help them find the best treatment option."If you're not happy with your treatment, find a dermatologist who specializes in psoriasis, or is comfortable using these biologics and systemic medications," said Liao.

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