Original article
Treatment of erythrodermic psoriasis with biologics: A systematic review

https://doi.org/10.1016/j.jaad.2020.03.073Get rights and content

Background

Biologic medications for plaque psoriasis have been used to treat erythrodermic psoriasis (EP). Since the guidelines for management of EP were published, new biologic medications have been approved for the treatment of plaque psoriasis.

Objective

To analyze the evidence of biologic medications in the treatment of EP based on response and tolerability.

Methods

A comprehensive search was conducted with the PubMed, Cochrane Library, Embase, and Scopus databases through December 31, 2018. Studies reporting 1 or more cases of EP, defined as >75% body surface area involvement, in patients aged ≥18 years treated with biologics were included. Baseline Psoriasis Area and Severity Index score, score improvement, and adverse events were documented. Adequate response to treatment was defined as Psoriasis Area and Severity Index ≥50.

Results

Included were 43 articles, yielding a total of 179 patients. Most patients responded at some point during treatment, with a higher level of evidence for infliximab, ustekinumab, ixekizumab, and guselkumab. Infection was the most common adverse event (n = 35).

Limitations

Data are limited to case reports, case series, and uncontrolled studies.

Conclusion

Patients with EP treated with biologics demonstrated positive responses and treatment was well-tolerated, with a weak recommendation and limited quality of evidence in favor of infliximab, ustekinumab, ixekizumab, and guselkumab.

Section snippets

Search strategy

This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.8 A primary literature search was conducted with the databases PubMed, Scopus, Embase, and Cochrane Library. We identified eligible articles from database inception to December 31, 2018. The search terms were “biologics” and “erythrodermic psoriasis,” “biologic” and “erythrodermic psoriasis,” “(drug name)” and “erythrodermic psoriasis.” Drug names included secukinumab, ixekizumab,

Systematic search results

We included 43 articles yielding 179 patients with EP treated with biologic medications (Fig 1). Case reports comprised 65.1% of the articles, followed by case series (14.0%) and open-label studies (11.6%). There were 3 retrospective studies and 1 open prospective study. Sixteen articles reported treatment with infliximab,16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 10 with ustekinumab,32, 33, 34, 35, 36, 37, 38, 39, 40, 41 4 with etanercept,42, 43, 44, 45 5 with secukinumab,46

Discussion

We aim to update the recommendations for treating EP with biologics published by Levin et al7 in 2012. Since their publication, new biologics have been approved for the treatment of plaque psoriasis. There is a lack of randomized, double-blind, controlled trials and head-to-head comparisons. Therefore, recommending any of the biologics as a first-line treatment for the management of EP is a challenge. Recommendations for each biologic are presented in Table II. Overall, ustekinumab was the most

Conclusion

Biologic therapy in patients with EP seems to be well-tolerated and demonstrated a positive response. Recommendations for biologic agent therapy in EP are based on limited evidence. We recommend infliximab or ustekinumab in acute, severe cases of EP as first-line biologic agents. IL-23 and IL-17 inhibitor agents seem to be a promising category of biologic treatment of EP and can also be considered as first-line therapy based on their level of evidence. Etanercept and adalimumab can be used in

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  • Cited by (0)

    Funding sources: None.

    Conflicts of interest: None disclosed.

    IRB approval status: Not necessary for this systematic review due to all the data being taken from public, anonymous literature.

    Reprints are not available from the authors.

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