Case and Research Letter
Erythrodermic Psoriasis Successfully Treated With Brodalumab: A Case Series
Psoriasis eritrodérmica exitosamente tratada con Brodalumab: serie de casos
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Sun, S. Duarte, L. Soares-de-Almeida" "autores" => array:3 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Sun" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Duarte" ] 2 => array:2 [ "nombre" => "L." 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Mota, P. Mendes-Bastos" "autores" => array:2 [ 0 => array:2 [ "nombre" => "F." "apellidos" => "Mota" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Mendes-Bastos" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731023003502?idApp=UINPBA000044" "url" => "/00017310/0000011400000006/v1_202306061231/S0001731023003502/v1_202306061231/es/main.assets" ] ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letter</span>" "titulo" => "Erythrodermic Psoriasis Successfully Treated With Brodalumab: A Case Series" "tieneTextoCompleto" => true "saludo" => "To the Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "547" "paginaFinal" => "549" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "F. Mota, P. Mendes-Bastos" "autores" => array:2 [ 0 => array:4 [ "nombre" => "F." "apellidos" => "Mota" "email" => array:1 [ 0 => "fernandojrmota@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "Mendes-Bastos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Photobiology and Cutaneous Immunology Unit, Hospital Senhora da Oliveira, Guimarães, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Dermatology Center, Hospital CUF Descobertas, Lisboa, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Psoriasis eritrodérmica exitosamente tratada con Brodalumab: serie de casos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2697 "Ancho" => 2020 "Tamanyo" => 722478 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Case 1 – patient with erythrodermic psoriasis at baseline (a) and after 6 (b) and 14 (c) weeks of first Brodalumab injection; case 2 – patient with erythrodermic psoriasis at baseline (d) and after 4 (e) and 8 (f) weeks of first Brodalumab injection; case 3 – patient with erythrodermic psoriasis at baseline (g) and after 4 (h) and 8 (i) weeks of first Brodalumab injection.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Erythrodermic psoriasis (EP) is a rare and severe form of the disease characterized by diffuse redness and scaling, covering more than 90% of the body surface area (BSA) and affects 1–2.25% of patients with psoriasis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Although a complex interplay of Th1, Th2, and Th17 inflammatory pathways seems to be involved in EP pathophysiology, recent findings showed that IL-17 responses are the dominant signal in erythrodermic psoriasis, suggesting that anti-IL-17 agents could represent an effective therapeutic option.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Brodalumab is a fully human monoclonal antibody that targets the IL-17 receptor A, inhibiting the biological activity of different isoforms of IL-17 (IL-17A, A/F, F, C and E) with a different mechanism of action when compared to other anti-IL17A biologic drugs.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3,4</span></a> A phase III study in Japan showed that brodalumab significantly improved the signs and symptoms of patients with EP throughout 52 weeks, with a favorable safety profile, suggesting that this drug might be a promising treatment option for EP.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> A small number of real-life cases of EP successfully treated with brodalumab have been described, although long-term efficacy and safety data is lacking.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6,7</span></a> We report three cases of real-life patients with EP achieving complete clearance after brodalumab treatment, with no adverse events reported during a follow-up period of 52–116 weeks.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The first case is a 40-year-old male with a long history of plaque psoriasis, several comorbidities (dyslipidemia and excessive alcohol use) and previous multiple failures to topicals, acitretin, ciclosporin, infliximab and ustekinumab. The patient presented with severe EP, a BSA of 100%, a PASI score of 48 and a DLQI of 27 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a), without psoriatic arthritis (PsA). Given the high impact on quality of life and the intense itch, the patient initiated brodalumab at labeled dosage. Significant improvement was observed: 6 weeks after the first injection, PASI score decreased to 21 (ΔPASI 57), BSA involvement decreased to 70% and the itching also disappeared (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b). After 14 weeks follow-up, BSA involvement was <1%, the absolute PASI (aPASI) was <1 (ΔPASI ∼100) with no impact on quality of life (DLQI 0) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>c). No adverse events have been observed during treatment with brodalumab. After 104 weeks follow-up, the disease is still in remission.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The second case is a 59-year-old male with a long history of plaque psoriasis and multiple comorbidities (obesity, dyslipidemia, hypertension, and excessive alcohol use), previously treated with topicals, acitretin and phototherapy. The patient presented with a BSA involvement of 90%, a PASI score of 43 and a DLQI score of 25 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>d), without PsA. The patient referred no articular pain and tested negative for latent tuberculosis (TB) infection. Brodalumab was initiated at labeled dose and significant improvement was observed just 4 weeks after the first injection: PASI score decreased to 7 (ΔPASI<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>75) and BSA involvement decreased to 10% (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>e). After 8 weeks follow-up, the BSA was <1%, aPASI<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>1 (ΔPASI ∼100), with no impact in quality of life (DLQI 0) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>f) and no adverse events, which is maintained after 52 weeks of follow-up.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The third case is a 43-year-old male, smoker, with plaque psoriasis since he was 16-years old, referred due to a worsening of his psoriasis in the past 5-years. Patient presented a diffuse cutaneous redness with a BSA of 90%, a PASI score of 31 and a DLQI of 18 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>g), without PsA, and was naïve to systemic therapy. As comorbidities, this patient had a confirmed hepatitis C (HCV) infection and tested positive for latent TB. After curing HCV (sofosbuvir/velpatasvir) and receiving treatment for latent TB (isoniazid), the patient was started on brodalumab at the labeled dose. Remarkable improvement was observed: PASI 90 response and DLQI 0 at week 4 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>h) and PASI 100 response and DLQI 0 at week 8 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>i). After 116 weeks follow-up, aPASI 0 and DLQI 0 are maintained, with no observed adverse events.</p><p id="par0030" class="elsevierStylePara elsevierViewall">All cases showed a high efficacy and good safety profile of brodalumab in the treatment of EP in the real-world setting, despite failure or contra-indication to previous treatments. Brodalumab also showed a rapid onset of action, returning patients’ quality of life in the short and long-term. Although specifically targeting Th17 mediated inflammation, the clinical benefit of brodalumab in erythrodermic psoriasis might be explained by its unique mechanism of action, inhibiting a wider spectrum of the IL-17 cytokine family. In fact, the inability of other biologic agents (anti-IL17A, -IL12/23 and -IL23) to block the entire IL-17 cell line, in particular IL-17C and IL17-E, might explain the appearance of flares and secondary therapeutic failures as reported here in case 1 and in another previously published case.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4,6,8,9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion, brodalumab represents a good option for EP as both rapid onset of action and favorable long-term efficacy/safety profile are needed. Further studies with larger sample sizes are needed to confirm brodalumab's clinical benefit for this challenging form of psoriasis.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">F. Mota has received honoraria for acting as a consultant and/or as a speaker for Galderma, Janssen, LEO Pharma, Lilly, Novartis, Pfizer and Sanofi Genzyme.</p><p id="par0045" class="elsevierStylePara elsevierViewall">He has also worked as a co-investigator in clinical trials supported by Amgen and Novartis.</p><p id="par0050" class="elsevierStylePara elsevierViewall">P Mendes-Bastos has received honoraria for acting as a consultant and/or as a speaker for AbbVie, Janssen, Novartis, LEO Pharma, Almirall, Sanofi, Viatris, L’Oréal and Cantabria Labs. He has also worked as a principal investigator in clinical trials supported by AbbVie, Sanofi and Novartis.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2697 "Ancho" => 2020 "Tamanyo" => 722478 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Case 1 – patient with erythrodermic psoriasis at baseline (a) and after 6 (b) and 14 (c) weeks of first Brodalumab injection; case 2 – patient with erythrodermic psoriasis at baseline (d) and after 4 (e) and 8 (f) weeks of first Brodalumab injection; case 3 – patient with erythrodermic psoriasis at baseline (g) and after 4 (h) and 8 (i) weeks of first Brodalumab injection.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A systematic review of treatment strategies for erythrodermic psoriasis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "K.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 18 | 10 | 28 |
| 2024 October | 126 | 65 | 191 |
| 2024 September | 136 | 42 | 178 |
| 2024 August | 201 | 77 | 278 |
| 2024 July | 166 | 51 | 217 |
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| 2024 May | 161 | 46 | 207 |
| 2024 April | 132 | 38 | 170 |
| 2024 March | 156 | 40 | 196 |
| 2024 February | 151 | 40 | 191 |
| 2024 January | 150 | 26 | 176 |
| 2023 December | 150 | 31 | 181 |
| 2023 November | 164 | 43 | 207 |
| 2023 October | 110 | 51 | 161 |
| 2023 September | 133 | 34 | 167 |
| 2023 August | 94 | 22 | 116 |
| 2023 July | 112 | 45 | 157 |
| 2023 June | 170 | 37 | 207 |
| 2023 May | 68 | 30 | 98 |
| 2023 April | 63 | 26 | 89 |
| 2023 March | 14 | 24 | 38 |
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