ABSTRACT
Patients who have both erythrodermic psoriasis and advanced ovarian cancer are uncommon in clinical practice. This case study presents the case of a patient diagnosed with erythrodermic psoriasis for a duration exceeding 4 years. The patient was administered ixekizumab and adalimumab, but no remission was observed during the illness. The patient was diagnosed with metastatic ovarian serous adenocarcinoma involving multiple lymph nodes and liver in 2022. During her bevacizumab treatment, she experienced a complete remission of psoriasis without any other management for psoriasis.
Keywords: bevacizumab, erythrodermic psoriasis, ovarian serous adenocarcinoma, vascular endothelial growth factor a
Key Clinical Message
Bevacizumab, a monoclonal antibody targeting vascular endothelial growth factor (VEGF), is approved for the treatment of multiple malignancies but has not been applied in psoriasis. We report a psoriasis patient whose cutaneous lesions improved during bevacizumab therapy for metastatic ovarian serous adenocarcinoma. This observation indicates that bevacizumab may possess promising therapeutic potential for psoriasis.
Patient showed psoriasis lesions before bevacizumab infusion.
1. Introduction
Erythrodermic psoriasis (EP), also known as psoriatic exfoliative dermatitis, is a type of psoriasis characterized by diffuse erythema, swelling, and extensive desquamation throughout the body, affecting a large part of the body surface area (more than 90%). Erythrodermic psoriasis (EP) is a severe and rare variant of psoriasis, with an estimated prevalence of 1%–2.25% among psoriatic patients [1]. A cross‐sectional study from 2006 to 2016 indicated that erythrodermic psoriasis is more prevalent in Asian populations [2]. Its mortality rate during the active phase is higher than that of plaque psoriasis. Bevacizumab is a monoclonal antibody that targets vascular endothelial growth factor (VEGF) and is used to treat various types of cancer. At present, its application in treating erythrodermic psoriasis remains limited.
2. Case Presentation
2.1. Chief Complaints
A 60‐year‐old female patient presented with complaints of diffuse erythema and extensive desquamation all over the body for more than 4 years.
2.2. History of Present Illness
More than 4 years ago, the patient was diagnosed with EP. From March 2022 to June 2022, she received treatment with ixekizumab (160 mg subcutaneously at Week 0, followed by 80 mg at Weeks 2, 4, 6, 8, 10, and 12, then a maintenance dose of 80 mg every 4 weeks). Due to poor therapeutic response, the regimen was switched to adalimumab from July 2022 to October 2022 (80 mg subcutaneously as an initial dose, followed by 80 mg subcutaneously every 2 weeks, starting 1 week after the first dose). However, a satisfactory effect was still not achieved. In December 2022, she was also diagnosed with metastatic ovarian serous adenocarcinoma (FIGO stage IVb), leading to the suspension of treatment for erythrodermic psoriasis.
2.3. Physical Examination
The patient has erythemas all over the body, accompanied by scattered scales throughout the body (Figure 1) in January 2023. The patient's Dermatology Life Quality Index (DLQI) score was 20, and her Psoriasis Area and Severity Index (PASI) score was 31.
FIGURE 1.
Patient showed psoriasis lesions before bevacizumab infusion.
2.4. Auxiliary Examinations
The pathological result of the skin biopsy showed hyperkeratosis with parakeratosis in the epidermis. Several foci of microabscesses were visible in the superficial layer of the epidermis. The spinous layer was thickened, and the rete ridges extended downward at approximately the same level. Lymphocyte infiltration, a small amount of eosinophil infiltration, and a small amount of pigmentation were observed in the superficial layer of the dermis. A full abdominal contrast‐enhanced CT (Figure 2) revealed bilateral adnexal changes, specifically a multilocular cystic‐solid mass. The lesions in both adnexa were fused and protruded into the Douglas pouch, with a maximum transverse section measuring approximately 13.8 cm by 9.3 cm. The enhanced scan showed uneven enhancement and an unclear boundary, making the mass indistinct from the upper segment of the rectum and the pelvic small intestine. These findings suggested a possible neoplastic change, such as ovarian cancer, with potential metastasis. Enlarged lymph nodes were observed around the abdominal aorta, bilateral common iliac arteries, and bilateral inguinal regions, which was suggestive of metastasis. Multiple areas of slightly thickened peritoneum and increased density of the omentum were noted, requiring peritoneal metastasis to be ruled out. A slightly hypodense shadow was identified in the upper segment of the posterior right lobe of the liver, which raised the possibility of metastasis, among other considerations. A pathological biopsy of the ovarian space‐occupying lesion, obtained via puncture, revealed adenocarcinoma. Based on immunohistochemistry, this was considered to be a serous adenocarcinoma of the adnexa.
FIGURE 2.
In pelvic CT images, the yellow arrow indicates the lesions of ovarian serous adenocarcinoma before bevacizumab treatment.
2.5. Final Diagnosis
The final clinical diagnosis was erythrodermic psoriasis and metastatic ovarian serous adenocarcinoma.
2.6. Treatment
From January 4, 2023, to May 20, 2023, the patient underwent six cycles of an ‘albumin‐bound paclitaxel 260 mg/m2 plus carboplatin area under the curve 5’ chemotherapy regimen. From June 2, 2023, to January 24, 2024, she received ten cycles of bevacizumab 15 mg/kg injections for maintenance‐targeted therapy.
2.7. Outcome and Follow‐Up
Follow‐up evaluations were conducted at 3, 6, and 12 months after the completion of combination chemotherapy plus bevacizumab therapy. The patient demonstrated a remarkable improvement in skin lesions within 2 months after the first bevacizumab infusion. After 10 cycles of bevacizumab treatment, follow‐up assessments revealed complete clearance of the skin lesions (Figure 3). Objective tumor response was evaluated according to Response Evaluation Criteria In Solid Tumors (RECIST 1.1) criteria, and Partial Response (a decrease of at least 30% in the sum of diameters of target lesions, compared to baseline) was achieved in September 2023 (Figure 4). Meanwhile, the patient's serum CA‐125 level showed a marked decline, from 951 U/mL in October 2022 to within the normal range (Figure 5). The patient's DLQI and PASI score showed significant progress (Figure 6). The patient was concerned about the prognosis after being diagnosed with ovarian cancer. She now faces her condition bravely, holds confidence in recovery, and accepts the situation calmly.
FIGURE 3.
Patient showing complete clearance of psoriatic lesions after bevacizumab infusion.
FIGURE 4.
In pelvic CT images, the yellow arrow indicates the lesions of ovarian serous adenocarcinoma after bevacizumab treatment.
FIGURE 5.
The patient's serum CA‐125 level showed a significant decrease after bevacizumab infusion.
FIGURE 6.
The patient's DLQI and PASI score showed significant progress after bevacizumab infusion.
3. Discussion
Psoriasis is an immune‐mediated inflammatory dermatosis characterized by an inflammatory ring. While angiogenesis in lesional skin supplies the energy required for epidermal keratinocyte proliferation, the contribution of this process to the pathogenesis of psoriasis has yet to be extensively investigated [3]. Vascular endothelial growth factor (VEGF) is a key driver of angiogenesis, mediated by its binding to VEGF receptors (VEGFRs), and is upregulated in psoriasis [4]. Among its family members, Vascular endothelial growth factor A (VEGFA) plays a critical role in the pathogenesis of the disease, which may be related to VEGFA promoting the aberrant expression of keratin in psoriatic skin tissue and the proliferation of keratinocytes [3]. The VEGFA levels in the plasma of patients with psoriasis are also increased, which is related to the severity of the disease [5]. Blockage of VEGF prevents the development of skin inflammation and reverses the inflammatory skin phenotype [6]. Bevacizumab—a monoclonal antibody targeting VEGFA—entered clinical practice over 15 years ago; it emerged as one of the earliest targeted cancer therapies and the first approved angiogenesis inhibitor. Initially approved to be used with chemotherapy for metastatic colorectal cancer, its indications have since expanded to encompass metastatic nonsmall‐cell lung cancer, glioblastoma, liver cancer, ovarian cancer, and cervical cancer [7]. Bevacizumab binds to VEGFA and its isoforms, inhibiting the interaction between VEGF and its receptors (VEGFRs). This mechanism subsequently suppresses the formation of new blood vessels and induces regression of existing vasculature [8]. Akman et al. [9] documented complete psoriasis remission in a patient with metastatic colon cancer treated with bevacizumab and combination chemotherapy, with no additional psoriasis‐directed therapy administered. G6‐31, a monoclonal antibody with potent neutralizing activity against both human and murine VEGF, has been shown to exert a significant therapeutic effect in a murine model of psoriasis‐like cutaneous inflammation [10]. This result suggests that anti‐VEGF therapy can ameliorate the psoriasis‐like skin phenotype, including associated epidermal abnormalities [11]. However, there is a case report describing a patient with rectal cancer complicated by erythrodermic psoriasis who, despite showing no response to prior bevacizumab treatment, experienced significant improvement in skin symptoms during panitumumab therapy [12]. At present, antiangiogenesis therapy has not yet become a mainstream treatment for psoriasis, and the currently available antiangiogenic drugs still exhibit certain side effects. For instance, bevacizumab may cause gastrointestinal perforation, bleeding, hypertension crisis, nephrotic syndrome, and embolism [7]. Psoriasis patients often have coexisting conditions, including hypertension and metabolic syndrome, that often preclude the use of antiangiogenic therapy. It is postulated that psoriasis patients with high VEGFA expression may be more prone to angiogenesis and consequently more susceptible to developing severe disease phenotypes [3]. This unique patient subgroup is most likely to benefit from anti‐VEGFA treatment strategies, thereby offering clinicians opportunities for personalized management of psoriasis [13]. Based on these findings, we infer that bevacizumab may represent a useful therapeutic option for the clinical subset of psoriasis patients who develop a severe phenotype and exhibit high levels of VEGFA.
Author Contributions
Na Wang: data curation, formal analysis, writing – original draft, writing – review and editing. Lei Li: writing – review and editing. Yongqiang Zhang: writing – review and editing.
Funding
The authors have nothing to report.
Consent
Written informed consent was obtained from the patient for the publication of this case report and any accompanying images.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
The authors have nothing to report.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.