Case and Research Letters
Good Response of Hyperkeratotic Palmoplantar Psoriasis to Ustekinumab
Psoriasis hiperqueratósica palmoplantar con excelente respuesta a ustekinumab
A. Nuño-González
, E. Gómez de la Fuente, F.J. Vicente-Martín, J.L. López-Estebaranz
Corresponding author
Unidad de Dermatología, Hospital Universitario Fundación Alcorcón, Madrid, Spain
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Nuño-González, E. Gómez de la Fuente, F.J. Vicente-Martín, J.L. López-Estebaranz" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Nuño-González" "email" => array:1 [ 0 => "anuno@fhalcorcon.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "E." "apellidos" => "Gómez de la Fuente" ] 2 => array:2 [ "nombre" => "F.J." "apellidos" => "Vicente-Martín" ] 3 => array:2 [ "nombre" => "J.L." "apellidos" => "López-Estebaranz" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Unidad de Dermatología, Hospital Universitario Fundación Alcorcón, Madrid, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Psoriasis hiperqueratósica palmoplantar con excelente respuesta a ustekinumab" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1125 "Ancho" => 1500 "Tamanyo" => 149139 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Excellent response after 16 weeks’ treatment with ustekinumab.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Although only a small area of the body is affected in palmoplantar psoriasis or psoriasis of the palms and soles, this condition causes considerable functional impairment due to hyperkeratosis, fissures, and erythema, and occasionally inflammation and pustules. These symptoms may seriously interfere with the patient's quality of life and may be disabling.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Moreover, the lack of a standard treatment hinders the therapeutic management of this clinical variant. We report a case of hyperkeratotic palmoplantar psoriasis that had not responded to several conventional therapies but responded well to treatment with ustekinumab.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 56-year-old man with a 1.5-year history of palmoplantar psoriasis whose treatment history at another hospital was as follows: high potency topical corticosteroids and calcipotriol (no improvement); topical psoralen UV-A therapy 3 times a week for 6 months, (poor response); and methotrexate 15<span class="elsevierStyleHsp" style=""></span>mg/wk associated with elevated transaminase values (5 times baseline) and marked gastrointestinal symptoms that led to withdrawal of treatment after 2 months.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient presented at our hospital with severe palmoplantar hyperkeratosis, fissuring, and 100% involvement of the palms and soles; it was difficult for him to walk and carry out his daily activities (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). There were no other lesions or joint involvement. Treatment with acitretin 50<span class="elsevierStyleHsp" style=""></span>mg/d (weight 76<span class="elsevierStyleHsp" style=""></span>kg, 0.66<span class="elsevierStyleHsp" style=""></span>mg/kg) resulted in some improvement, but was poorly tolerated because of dry skin, cheilitis, joint pain, gynecomastia, alopecia, and hypertriglyceridemia (352<span class="elsevierStyleHsp" style=""></span>mg/dL). Reduction of the dose to 35<span class="elsevierStyleHsp" style=""></span>mg yielded little improvement in the side effects and worsening of the lesions. Consequently, treatment was suspended after 9 months.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Owing to the failure of conventional therapies, we decided to begin treatment with a biologic agent. As the patient was a frequent traveler who spent long periods away from home, ustekinumab 45<span class="elsevierStyleHsp" style=""></span>mg was prescribed and administered according to the conventional regimen (initial dose followed by another 4 weeks later and every 3 months thereafter). We successfully applied for a compassionate use permit and the patient duly signed informed consent. At 16 weeks, after receiving 2 doses of ustekinumab 45<span class="elsevierStyleHsp" style=""></span>mg, the patient reported complete resolution of his disease (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Clinical findings and tests showed no drug-related side effects. The patient has continued with the treatment for the last 12 months with excellent results and no adverse events.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Hyperkeratotic palmoplantar psoriasis has traditionally been treated with the drugs used for psoriasis vulgaris (with varying, but generally poor, results) and often represents a challenge to dermatologists.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> In cases where conventional therapies have failed, anti-tumor necrosis factor agents have proved effective.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a> However, cases have also been reported in which these agents have paradoxically been associated with new onset or worsening of palmoplantar psoriasis or pustulosis. The mechanism is poorly understood and biologic drugs should therefore be used with caution in this setting.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Efalizumab is another biologic agent that has proved to be effective in palmoplantar psoriasis,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> although international sales of this drug have now been discontinued because of an increased risk of progressive multifocal leukocytopenia.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Ustekinumab – the biologic agent most recently approved for use in psoriasis – is a fully human monoclonal antibody that binds to the shared p40 subunit of the interleukins (IL) 12 and IL-23 and blocks their action. To date, ustekinumab has only been studied in plaque psoriasis, and pustular, erythrodermic, and palmoplantar psoriasis are not, therefore, included in the summary of product characteristics; the only evidence available on its use in these variants comes from case series and isolated case reports. Since ustekinumab is a new drug, experience of its use in forms other than plaque psoriasis is scant. Daudén et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> reported a case of generalized pustular psoriasis that responded with excellent results following treatment with ustekinumab. In a series of 4 patients with palmoplantar pustulosis, Gerdes et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> reported good response in 1 patient, no response in 2 patients, and a partial response in the fourth. On the basis of these findings, they did not consider ustekinumab to be an appropriate treatment for regular use in this disease. Two other authors recently reported good results with ustekinumab in hyperkeratotic psoriasis in patients similar to ours.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,9</span></a> From a pathophysiologic standpoint, increased IL-23 expression has been observed not only in plaque psoriasis but also in palmoplantar psoriasis and hyperkeratotic hand dermatitis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Moreover, IL-23 stimulates production of IL-17 and IL-22, and the latter induces epidermal hyperplasia and acanthosis, key pathologic findings in psoriasis.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Thus, the inhibitory effect of ustekinumab on IL-23 could explain the improvement of palmoplantar hyperkeratosis treated with ustekinumab. However, further studies involving larger numbers of patients are needed to determine whether ustekinumab is useful in this setting.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">Dr. Almudena Nuño González, Dr. Enrique Gómez de la Fuente, and Dr. Francisco Javier Vicente Martín declare that they have no conflicts of interest.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Dr. José Luis López Estebaranz has taken part in clinical trials and evaluations for Janssen, Abbott, Pfizer, and Schering-Plough.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Nuño-González A, et al. Psoriasis hiperqueratósica palmoplantar con excelente respuesta a ustekinumab. Actas Dermosifiliogr. 2012;103:169–70.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1197 "Ancho" => 1500 "Tamanyo" => 187457 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Soles of the feet with marked hyperkeratosis prior to treatment.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1125 "Ancho" => 1500 "Tamanyo" => 149139 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Excellent response after 16 weeks’ treatment with ustekinumab.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Patients with palmoplantar psoriasis have more physical disability and discomfort than patients with other forms of psoriasis: implications for clinical practice" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 14 | 13 | 27 |
| 2024 October | 122 | 46 | 168 |
| 2024 September | 158 | 31 | 189 |
| 2024 August | 149 | 49 | 198 |
| 2024 July | 145 | 53 | 198 |
| 2024 June | 141 | 42 | 183 |
| 2024 May | 111 | 39 | 150 |
| 2024 April | 119 | 31 | 150 |
| 2024 March | 135 | 38 | 173 |
| 2024 February | 112 | 36 | 148 |
| 2024 January | 131 | 47 | 178 |
| 2023 December | 104 | 34 | 138 |
| 2023 November | 190 | 32 | 222 |
| 2023 October | 136 | 30 | 166 |
| 2023 September | 128 | 38 | 166 |
| 2023 August | 125 | 28 | 153 |
| 2023 July | 136 | 48 | 184 |
| 2023 June | 157 | 30 | 187 |
| 2023 May | 216 | 34 | 250 |
| 2023 April | 261 | 30 | 291 |
| 2023 March | 203 | 35 | 238 |
| 2023 February | 168 | 20 | 188 |
| 2023 January | 164 | 26 | 190 |
| 2022 December | 166 | 43 | 209 |
| 2022 November | 129 | 29 | 158 |
| 2022 October | 118 | 23 | 141 |
| 2022 September | 117 | 25 | 142 |
| 2022 August | 76 | 28 | 104 |
| 2022 July | 67 | 35 | 102 |
| 2022 June | 88 | 29 | 117 |
| 2022 May | 141 | 23 | 164 |
| 2022 April | 145 | 45 | 190 |
| 2022 March | 134 | 59 | 193 |
| 2022 February | 140 | 40 | 180 |
| 2022 January | 134 | 39 | 173 |
| 2021 December | 90 | 50 | 140 |
| 2021 November | 91 | 50 | 141 |
| 2021 October | 121 | 43 | 164 |
| 2021 September | 96 | 44 | 140 |
| 2021 August | 80 | 43 | 123 |
| 2021 July | 65 | 31 | 96 |
| 2021 June | 96 | 36 | 132 |
| 2021 May | 111 | 47 | 158 |
| 2021 April | 231 | 62 | 293 |
| 2021 March | 123 | 25 | 148 |
| 2021 February | 109 | 28 | 137 |
| 2021 January | 61 | 17 | 78 |
| 2020 December | 72 | 25 | 97 |
| 2020 November | 40 | 32 | 72 |
| 2020 October | 49 | 14 | 63 |
| 2020 September | 26 | 15 | 41 |
| 2020 August | 28 | 18 | 46 |
| 2020 July | 29 | 25 | 54 |
| 2020 June | 40 | 27 | 67 |
| 2020 May | 39 | 21 | 60 |
| 2020 April | 39 | 12 | 51 |
| 2020 March | 40 | 23 | 63 |
| 2020 February | 6 | 5 | 11 |
| 2020 January | 0 | 3 | 3 |
| 2019 December | 4 | 5 | 9 |
| 2019 November | 0 | 6 | 6 |
| 2019 October | 0 | 2 | 2 |
| 2019 September | 6 | 4 | 10 |
| 2019 August | 0 | 2 | 2 |
| 2019 July | 0 | 6 | 6 |
| 2019 June | 0 | 51 | 51 |
| 2019 May | 2 | 102 | 104 |
| 2019 April | 0 | 39 | 39 |
| 2019 March | 0 | 15 | 15 |
| 2019 February | 2 | 12 | 14 |
| 2019 January | 0 | 5 | 5 |
| 2018 December | 2 | 4 | 6 |
| 2018 November | 2 | 4 | 6 |
| 2018 October | 2 | 0 | 2 |
| 2018 September | 1 | 1 | 2 |
| 2018 August | 0 | 17 | 17 |
| 2018 July | 0 | 3 | 3 |
| 2018 June | 0 | 1 | 1 |
| 2018 May | 0 | 10 | 10 |
| 2018 March | 13 | 2 | 15 |
| 2018 February | 157 | 7 | 164 |
| 2018 January | 181 | 11 | 192 |
| 2017 December | 137 | 10 | 147 |
| 2017 November | 162 | 15 | 177 |
| 2017 October | 96 | 7 | 103 |
| 2017 September | 90 | 16 | 106 |
| 2017 August | 124 | 34 | 158 |
| 2017 July | 147 | 24 | 171 |
| 2017 June | 232 | 32 | 264 |
| 2017 May | 206 | 28 | 234 |
| 2017 April | 178 | 20 | 198 |
| 2017 March | 152 | 23 | 175 |
| 2017 February | 127 | 13 | 140 |
| 2017 January | 139 | 22 | 161 |
| 2016 December | 195 | 15 | 210 |
| 2016 November | 264 | 15 | 279 |
| 2016 October | 315 | 30 | 345 |
| 2016 September | 363 | 24 | 387 |
| 2016 August | 295 | 20 | 315 |
| 2016 July | 128 | 16 | 144 |
| 2016 June | 16 | 8 | 24 |
| 2016 May | 24 | 22 | 46 |
| 2016 April | 8 | 16 | 24 |
| 2016 March | 15 | 11 | 26 |
| 2016 February | 8 | 17 | 25 |
| 2016 January | 16 | 4 | 20 |
| 2015 December | 12 | 1 | 13 |
| 2015 November | 41 | 6 | 47 |
| 2015 October | 84 | 6 | 90 |
| 2015 September | 120 | 2 | 122 |
| 2015 August | 55 | 10 | 65 |
| 2015 July | 122 | 8 | 130 |
| 2015 June | 89 | 8 | 97 |
| 2015 May | 112 | 25 | 137 |
| 2015 April | 94 | 15 | 109 |
| 2015 March | 75 | 14 | 89 |
| 2015 February | 66 | 18 | 84 |
| 2015 January | 74 | 18 | 92 |
| 2014 December | 81 | 14 | 95 |
| 2014 November | 35 | 18 | 53 |
| 2014 October | 63 | 13 | 76 |
| 2014 September | 46 | 19 | 65 |
| 2014 August | 47 | 13 | 60 |
| 2014 July | 63 | 23 | 86 |
| 2014 June | 88 | 14 | 102 |
| 2014 May | 96 | 16 | 112 |
| 2014 April | 69 | 5 | 74 |
| 2014 March | 73 | 22 | 95 |
| 2014 February | 21 | 22 | 43 |
| 2014 January | 29 | 8 | 37 |
| 2013 December | 35 | 11 | 46 |
| 2013 November | 20 | 11 | 31 |
| 2013 October | 13 | 7 | 20 |
| 2013 September | 16 | 12 | 28 |
| 2013 August | 12 | 12 | 24 |
| 2013 July | 15 | 18 | 33 |
| 2013 June | 12 | 34 | 46 |
| 2013 May | 14 | 13 | 27 |
| 2013 April | 17 | 6 | 23 |
| 2013 March | 20 | 14 | 34 |
| 2013 February | 58 | 7 | 65 |
| 2013 January | 145 | 8 | 153 |
| 2012 December | 85 | 7 | 92 |
| 2012 October | 2 | 4 | 6 |
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