Prolonged cyclosporine treatment of severe or recalcitrant psoriasis: descriptive study in a series of 20 patients

Updates on the Treatment of Erythrodermic Psoriasis

Erythrodermic psoriasis (EP) is a rare variant of psoriasis, which is potentially life threatening and often resistant to conventional therapy. Biologics have revolutionized the treatment of plaque-type psoriasis, and shown promise in EP. However, due to the lack of head-to-head studies and the rarity of EP, no high level evidence-based treatment guidelines for EP have been established, and the evidence of treatment of EP is limited to case reports or small case series. Here, we present a narrative review focusing on the up-to-date information for the treatment of EP.

Persistence and effectiveness of nonbiologic systemic therapies for moderate-to-severe psoriasis in adults: a systematic review

Background

The persistence and effectiveness of systemic therapies for moderate‐to‐severe psoriasis in current clinical practice are poorly characterized.

Objectives

To systematically review observational studies investigating the persistence and effectiveness of acitretin, ciclosporin, fumaric acid esters (FAE) and methotrexate, involving at least 100 adult patients with moderate‐to‐severe psoriasis, exposed to therapy for ≥ 3 months.

Methods

MEDLINE, Embase, the Cochrane Library and PubMed were searched from 1 January 2007 to 1 November 2017 for observational studies reporting on persistence (therapy duration or the proportion of patients discontinuing therapy during follow‐up) or effectiveness [improvements in Psoriasis Area and Severity Index (PASI) or Physician's Global Assessment (PGA)]. This review was registered with PROSPERO, number CRD42018099771.

Results

Of 411 identified studies, eight involving 4624 patients with psoriasis were included. Variations in the definitions and analyses of persistence and effectiveness outcomes prevented a meta‐analysis from being conducted. One prospective multicentre study reported drug survival probabilities of 23% (ciclosporin), 42% (acitretin) and 50% (methotrexate) at 1 year. Effectiveness outcomes were not reported for either acitretin or ciclosporin. The persistence and effectiveness of FAE and methotrexate were better characterized, but mean discontinuation times ranged from 28 to 50 months for FAE and 7·7 to 22·3 months for methotrexate. At 12 months of follow‐up, three studies reported that 76% (FAE), 53% (methotrexate) and 59% (methotrexate) of patients achieved ≥ 75% reduction in PASI, and one reported that 76% of FAE‐exposed patients achieved a markedly improved or clear PGA.

Conclusions

The comparative persistence and effectiveness of acitretin, ciclosporin, FAE and methotrexate in real‐world clinical practice in the past decade cannot be well described due to the inconsistency of the methods used.

What's already known about this topic?

Research examining acitretin, ciclosporin, fumaric acid esters (FAE) and methotrexate for the treatment of moderate‐to‐severe psoriasis has focused on safety and efficacy in randomized controlled trials.

The persistence and effectiveness of acitretin, ciclosporin, FAE and methotrexate since the introduction of biologic therapies in real‐world clinical practice are poorly understood.

What does this study add?

This systematic review examines the persistence and effectiveness of methotrexate, acitretin, ciclosporin and FAE for moderate‐to‐severe psoriasis.

Data on the persistence and effectiveness of systemic therapies are lacking, particularly for acitretin and ciclosporin.

The definitions of persistence and reporting of effectiveness are inconsistent.

Further good‐quality observational studies are needed to explore the real‐world persistence and effectiveness of systemic treatments used for psoriasis.

Linked Comment: Garcia-Doval and Sbidian. Br J Dermatol 2019; 181:237.

Plain language summary available online

Erythrodermic psoriasis: pathophysiology and current treatment perspectives

Erythrodermic psoriasis (EP) is a rare and severe variant of psoriasis vulgaris, with an estimated prevalence of 1%-2.25% among psoriatic patients. The condition presents with distinct histopathologic and clinical findings, which include a generalized inflammatory erythema involving at least 75% of the body surface area. The pathogenesis of EP is not well understood; however, several studies suggest that the disease is associated with a predominantly T helper 2 (Th2) phenotype. Given the morbidity and potential mortality associated with the condition, there is a need for a better understanding of its pathophysiology. The management of EP begins with a comprehensive assessment of the patient's presentation and often requires multidisciplinary supportive measures. In 2010, the medical board of the US National Psoriasis Foundation published consensus guidelines advocating the use of cyclosporine or infliximab as first-line therapy in unstable cases, with acitretin and methotrexate reserved for more stable cases. Since the time of that publication, additional information regarding the efficacy of newer agents has emerged. We review the latest data with regard to the treatment of EP, which includes biologic therapies such as ustekinumab and ixekizumab.

Focus on five patients treated with cyclosporine up to 62 months

BACKGROUND

Cyclosporine is a validated treatment for moderate to severe psoriasis. Long-term cyclosporine administration may induce toxic effects. The duration of treatment usually ranges from 10 to 16 weeks. However, some patients may take cyclosporine for a longer time.

AIM

The objective of the present study is to evaluate the dose, efficacy and safety in long-term cyclosporine therapy.

PATIENTS AND METHODS

We studied the hospital records of patients with psoriasis treated with cyclosporine between 1 January 2009, and 30 April 2015. We decided to focus on patients who, for different reasons, have continued cyclosporine for more than 2 years.

RESULTS

Five patients (2.69%) had been assuming cyclosporine for up to 62 months and had achieved a substantial response with no toxic effects. All of them were concerned about recurrence and all patients had personal reasons to prefer Cyclosporine over other drugs, including: familiar history of neurodegenerative disease, desire for motherhood, easy availability on prescription, systemic scleroderma, belenophobia.

CONCLUSION

Cyclosporine is an acceptable monotherapy for psoriasis in selected patients. The prompt discontinuation of treatment usually results in resolution of any eventual toxicity.