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
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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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 4 | 1 | 5 |
| 2024 Octubre | 122 | 46 | 168 |
| 2024 Septiembre | 158 | 31 | 189 |
| 2024 Agosto | 149 | 49 | 198 |
| 2024 Julio | 145 | 53 | 198 |
| 2024 Junio | 141 | 42 | 183 |
| 2024 Mayo | 111 | 39 | 150 |
| 2024 Abril | 119 | 31 | 150 |
| 2024 Marzo | 135 | 38 | 173 |
| 2024 Febrero | 112 | 36 | 148 |
| 2024 Enero | 131 | 47 | 178 |
| 2023 Diciembre | 104 | 34 | 138 |
| 2023 Noviembre | 190 | 32 | 222 |
| 2023 Octubre | 136 | 30 | 166 |
| 2023 Septiembre | 128 | 38 | 166 |
| 2023 Agosto | 125 | 28 | 153 |
| 2023 Julio | 136 | 48 | 184 |
| 2023 Junio | 157 | 30 | 187 |
| 2023 Mayo | 216 | 34 | 250 |
| 2023 Abril | 261 | 30 | 291 |
| 2023 Marzo | 203 | 35 | 238 |
| 2023 Febrero | 168 | 20 | 188 |
| 2023 Enero | 164 | 26 | 190 |
| 2022 Diciembre | 166 | 43 | 209 |
| 2022 Noviembre | 129 | 29 | 158 |
| 2022 Octubre | 118 | 23 | 141 |
| 2022 Septiembre | 117 | 25 | 142 |
| 2022 Agosto | 76 | 28 | 104 |
| 2022 Julio | 67 | 35 | 102 |
| 2022 Junio | 88 | 29 | 117 |
| 2022 Mayo | 141 | 23 | 164 |
| 2022 Abril | 145 | 45 | 190 |
| 2022 Marzo | 134 | 59 | 193 |
| 2022 Febrero | 140 | 40 | 180 |
| 2022 Enero | 134 | 39 | 173 |
| 2021 Diciembre | 90 | 50 | 140 |
| 2021 Noviembre | 91 | 50 | 141 |
| 2021 Octubre | 121 | 43 | 164 |
| 2021 Septiembre | 96 | 44 | 140 |
| 2021 Agosto | 80 | 43 | 123 |
| 2021 Julio | 65 | 31 | 96 |
| 2021 Junio | 96 | 36 | 132 |
| 2021 Mayo | 111 | 47 | 158 |
| 2021 Abril | 231 | 62 | 293 |
| 2021 Marzo | 123 | 25 | 148 |
| 2021 Febrero | 109 | 28 | 137 |
| 2021 Enero | 61 | 17 | 78 |
| 2020 Diciembre | 72 | 25 | 97 |
| 2020 Noviembre | 40 | 32 | 72 |
| 2020 Octubre | 49 | 14 | 63 |
| 2020 Septiembre | 26 | 15 | 41 |
| 2020 Agosto | 28 | 18 | 46 |
| 2020 Julio | 29 | 25 | 54 |
| 2020 Junio | 40 | 27 | 67 |
| 2020 Mayo | 39 | 21 | 60 |
| 2020 Abril | 39 | 12 | 51 |
| 2020 Marzo | 40 | 23 | 63 |
| 2020 Febrero | 6 | 5 | 11 |
| 2020 Enero | 0 | 3 | 3 |
| 2019 Diciembre | 4 | 5 | 9 |
| 2019 Noviembre | 0 | 6 | 6 |
| 2019 Octubre | 0 | 2 | 2 |
| 2019 Septiembre | 6 | 4 | 10 |
| 2019 Agosto | 0 | 2 | 2 |
| 2019 Julio | 0 | 6 | 6 |
| 2019 Junio | 0 | 51 | 51 |
| 2019 Mayo | 2 | 102 | 104 |
| 2019 Abril | 0 | 39 | 39 |
| 2019 Marzo | 0 | 15 | 15 |
| 2019 Febrero | 2 | 12 | 14 |
| 2019 Enero | 0 | 5 | 5 |
| 2018 Diciembre | 2 | 4 | 6 |
| 2018 Noviembre | 2 | 4 | 6 |
| 2018 Octubre | 2 | 0 | 2 |
| 2018 Septiembre | 1 | 1 | 2 |
| 2018 Agosto | 0 | 17 | 17 |
| 2018 Julio | 0 | 3 | 3 |
| 2018 Junio | 0 | 1 | 1 |
| 2018 Mayo | 0 | 10 | 10 |
| 2018 Marzo | 13 | 2 | 15 |
| 2018 Febrero | 157 | 7 | 164 |
| 2018 Enero | 181 | 11 | 192 |
| 2017 Diciembre | 137 | 10 | 147 |
| 2017 Noviembre | 162 | 15 | 177 |
| 2017 Octubre | 96 | 7 | 103 |
| 2017 Septiembre | 90 | 16 | 106 |
| 2017 Agosto | 124 | 34 | 158 |
| 2017 Julio | 147 | 24 | 171 |
| 2017 Junio | 232 | 32 | 264 |
| 2017 Mayo | 206 | 28 | 234 |
| 2017 Abril | 178 | 20 | 198 |
| 2017 Marzo | 152 | 23 | 175 |
| 2017 Febrero | 127 | 13 | 140 |
| 2017 Enero | 139 | 22 | 161 |
| 2016 Diciembre | 195 | 15 | 210 |
| 2016 Noviembre | 264 | 15 | 279 |
| 2016 Octubre | 315 | 30 | 345 |
| 2016 Septiembre | 363 | 24 | 387 |
| 2016 Agosto | 295 | 20 | 315 |
| 2016 Julio | 128 | 16 | 144 |
| 2016 Junio | 16 | 8 | 24 |
| 2016 Mayo | 24 | 22 | 46 |
| 2016 Abril | 8 | 16 | 24 |
| 2016 Marzo | 15 | 11 | 26 |
| 2016 Febrero | 8 | 17 | 25 |
| 2016 Enero | 16 | 4 | 20 |
| 2015 Diciembre | 12 | 1 | 13 |
| 2015 Noviembre | 41 | 6 | 47 |
| 2015 Octubre | 84 | 6 | 90 |
| 2015 Septiembre | 120 | 2 | 122 |
| 2015 Agosto | 55 | 10 | 65 |
| 2015 Julio | 122 | 8 | 130 |
| 2015 Junio | 89 | 8 | 97 |
| 2015 Mayo | 112 | 25 | 137 |
| 2015 Abril | 94 | 15 | 109 |
| 2015 Marzo | 75 | 14 | 89 |
| 2015 Febrero | 66 | 18 | 84 |
| 2015 Enero | 74 | 18 | 92 |
| 2014 Diciembre | 81 | 14 | 95 |
| 2014 Noviembre | 35 | 18 | 53 |
| 2014 Octubre | 63 | 13 | 76 |
| 2014 Septiembre | 46 | 19 | 65 |
| 2014 Agosto | 47 | 13 | 60 |
| 2014 Julio | 63 | 23 | 86 |
| 2014 Junio | 88 | 14 | 102 |
| 2014 Mayo | 96 | 16 | 112 |
| 2014 Abril | 69 | 5 | 74 |
| 2014 Marzo | 73 | 22 | 95 |
| 2014 Febrero | 21 | 22 | 43 |
| 2014 Enero | 29 | 8 | 37 |
| 2013 Diciembre | 35 | 11 | 46 |
| 2013 Noviembre | 20 | 11 | 31 |
| 2013 Octubre | 13 | 7 | 20 |
| 2013 Septiembre | 16 | 12 | 28 |
| 2013 Agosto | 12 | 12 | 24 |
| 2013 Julio | 15 | 18 | 33 |
| 2013 Junio | 12 | 34 | 46 |
| 2013 Mayo | 14 | 13 | 27 |
| 2013 Abril | 17 | 6 | 23 |
| 2013 Marzo | 20 | 14 | 34 |
| 2013 Febrero | 58 | 7 | 65 |
| 2013 Enero | 145 | 8 | 153 |
| 2012 Diciembre | 85 | 7 | 92 |
| 2012 Octubre | 2 | 4 | 6 |
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