A 64-year-old male with a 33-year history of psoriasis presented for evaluation of psoriasis that had worsened in the last 10 days with erythema and scaling affecting 90% of the body surface area (BSA). The Psoriasis Area Severity Index (PASI) score was 70.8 and the Physician Global Assessment (PGA) score was 5 (Figures 1 A–C), which met the criteria for erythrodermic psoriasis (EP). His body temperature reached 39.1°C. Laboratory testing revealed an elevated C-reactive protein level (172.3 mg/l, reference range: 0–6 mg/l), rapid erythrocyte sedimentation rate (101 mm/h, reference range: 0–15 mm/h), and hypokalaemia (3.33 mmol/l, reference range: 3.5–5.5 mmol/l); glutamic-pyruvic transaminase and glutamic oxaloacetic transaminase were normal (32 U/l and 34 U/l, respectively, reference range: 0–40 U/l), kidney function tests, blood glucose, blood lipid, immunoglobulin, and complement levels were all normal; abdominal ultrasonography was significant for cirrhosis; chest radiography and electrocardiography were normal.
Figure 1.
Skin lesions of the patient before and after ixekizumab treatment. A–C – Skin lesions on the trunk and lower limbs of the patient before ixekizumab treatment. D–F – Skin lesions on the trunk and lower limbs of the patient 2 days after ixekizumab treatment. G–I – Skin lesions on the trunk and lower limbs of the patient 2 weeks after ixekizumab treatment, cutaneous lesions resolved completely, only hyperpigmentation remained
In the past 33 years, he experienced recurrent psoriasis flares, methotrexate was used in his initial treatment. Ten years ago, he was diagnosed with drug-induced cirrhosis due to methotrexate by a specialist physician, then methotrexate was discontinued. Then, he was treated with cyclosporine and acitretin, however, the symptoms were not well-controlled. Therefore, a humanized monoclonal IgG antibody that neutralizes interleukin-17A (ixekizumab) was administered. Specifically, he received an initial dose of ixekizumab intravenously (160 mg) followed by 80 mg intravenously every 2 weeks.
Ixekizumab was highly effective with a significant resolution of skin lesions 2 days after administration (Figures 1 D–F). The post-treatment PASI and PGA scores were 19.6 (a 72.3% improvement) and 3, respectively. In addition, he defervesced 1 day after the administration. His PASI and PGA scores achieved 7.5 (an 89.4% improvement) and 2, respectively, at week 1. No lesions (PASI = 0 and BSA = 0; Figures 1 G–I) were observed at week 2. This good response was confirmed at the 4-month follow-up evaluation. The patient did not report any adverse effects.
Due to the low incidence of EP, studies related to ixekizumab have mostly been case reports and small-scale clinical studies, large-scale and randomized controlled clinical trials are lacking [1]. In a phase 3 clinical trial involving eight EP patients, ixekizumab was administered subcutaneously as follows: week 0 – 160 mg; weeks 2–12 – 80 mg every 2 weeks; and weeks 16–52 – 80 mg every 4 weeks. At week 52, 100% of EP patients achieved PASI 75 (75% decrease in PASI) and 75% of patients achieved PASI 90. The treatment effect was maintained through week 244 [2, 3]. Morita et al. [4] reported 5 EP patients who were administered ixekizumab every 2 weeks. At week 12, 2 patients achieved PASI 75 and one achieved PASI 90; at week 20, 3 patients reached PASI 75 and one reached PASI 90. These studies confirmed the efficacy of ixekizumab in EP patients.
Due to the history of drug-induced cirrhosis in the patient described herein and the poor curative effect using traditional medications, we selected ixekizumab for treatment. Complete resolution of the skin lesions was verified at week 2, which was more rapid than in previously reported cases, and no adverse effects occurred. The rapid response of ixekizumab brings new options and prospects for the treatment of EP and further studies of efficacy and safety are needed.
Acknowledgments
We sincerely thank the patient for providing the permission to share his information.
Funding Statement
Funding Medical and health science and technology development program of Shandong Province (No. 202004120116).
Ethical approval
The study was approved by the institutional research ethics committee of Dermatology Hospital of Shandong First Medical University.
Conflict of interest
The authors declare no conflict of interest.
References
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