Atezolizumab-Induced Acrodermatitis and Pustular Psoriasis in a Patient with Non-Small Cell Lung Cancer: A Rare Case Report

Introduction

Immune checkpoint inhibitors are new drugs approved for the treatment of many types of malignancies. Despite their wide use and unquestionable clinical benefits, these agents have also been associated with a unique spectrum of side effects known as immune-related adverse events. In this study, we report the first case of atezolizumab-induced pustular psoriasis and acrodermatitis.

Case Presentation

A 61-year-old woman presented to our department with erythematous-desquamative and pustular lesions involving all hands and feet fingers, inguinal region, and trunk, associated to severe psoriatic onychodystrophy. She was affected by non-small-cell lung carcinoma from 12 years, and 7 months before admission, she started a treatment with atezolizumab.

Conclusion

Immune checkpoint inhibitors such as atezolizumab are linked to a plethora of adverse events. Identifying and treating certain adverse skin events, particularly in cancer patients, can be a challenge, leading oncologists to discontinue immunotherapy. Our case shows how it is necessary to have a shared therapeutic algorithm in order to manage serious skin reactions in cancer patients and avoid disruption of the oncotherapy.

Anti-Interleukin-17s for successful management of pustular psoriasis

Generalised pustular psoriasis (GPP) and acrodermatitis continua of Hallopeau (ACH) are two rare entities included in the spectrum of pustular psoriasis (PP). Due to the lack of randomised controlled clinical trials and standardized guidelines, their treatment remains a challenge for clinicians. Thus, herein we report our centre experience with the successful use of interleukin (IL)-17 inhibitors in three patients affected by PP. We also provide a brief overview of the current knowledge concerning the role of IL-17 in PP pathogenesis and of the use of IL-17 inhibitors in the treatment of PP. Based on our experience, anti-IL-17 molecules may represent a valuable therapeutical option for patients affected by different PP subtypes.

Pustular Psoriasis: A Narrative Review of Recent Developments in Pathophysiology and Therapeutic Options

Pustular psoriasis is an unusual form of psoriasis that frequently presents clinical challenges for dermatologists. The condition presents with pustules on an erythematous background and has two distinct subtypes: localized disease on the palms and soles, called palmoplantar pustulosis (PPP), and generalized pustular psoriasis (GPP). The involvement of the fingers, toes, and nails is defined as a separate localized variant, acrodermatitis continua of Hallopeau, and is now thought to be a subset of PPP. The rarity of pustular psoriasis frequently makes the correct diagnosis problematic. In addition, treatment is limited by a relative lack of evidence-based therapeutic options. Current management is often based on existing therapies for standard plaque psoriasis. However, there remains a need for treatments with high, sustained efficacy and a rapid onset of action in pustular psoriasis. Recent advances in understanding of the pathogenesis of pustular psoriasis have provided insights into potential therapies. Treatment of pustular psoriasis is generally determined by the extent and severity of disease, and recent years have seen an increasing use of newer agents, including biologic therapies. Current classes of biologic therapies with US Food and Drug Administration and European Medicines Agency approval for treatment of moderate-to-severe plaque psoriasis in the USA (and elsewhere) include tumor necrosis factor alpha inhibitors (adalimumab, certolizumab pegol, etanercept, infliximab), interleukin (IL)-17 inhibitors (brodalumab, ixekizumab, secukinumab), an IL-12/23 inhibitor (ustekinumab), and IL-23 inhibitors (guselkumab, risankizumab, tildrakizumab). Recently, specific inhibitors of the IL-36 pathway have been evaluated in GPP and PPP, including spesolimab, an IL-36 receptor inhibitor which has shown promising results in GPP. The emerging drugs for pustular psoriasis offer the possibility of rapid and effective treatment with lower toxicities than existing therapies. Further research into agents acting on the IL-36 pathway and other targeted therapies has the potential to transform the future treatment of patients with pustular psoriasis. This article reviews the clinical features of PPP and GPP, and current understanding of the genetics and immunopathology of these conditions; it also provides an update on emerging treatments.

Pustular psoriasis is a skin condition where people develop small pus-filled blisters on their skin. Pustular psoriasis may affect certain areas of the body, such as the palms and/or the soles. This is called palmoplantar pustulosis (PPP for short). Another type of pustular psoriasis can affect most of the body called generalized pustular psoriasis (GPP for short). Not many people have PPP or GPP. Around 5–12 in every 10,000 people worldwide develop PPP. GPP is even rarer, affecting only 2–7 out of every 1 million people. In addition to being relatively uncommon, these conditions are challenging to treat. This article aims to help doctors who treat skin conditions (dermatologists) to identify and treat people with pustular psoriasis. Currently there is no standard treatment for GPP and PPP in the USA or Europe, but several medicines are approved for treatment of GPP in Japan. Doctors often use treatments that have been shown to work in plaque psoriasis, which is the most common type of psoriasis, to treat people with GPP and PPP. Traditional treatments for PPP and GPP are often not effective. Researchers are working on developing new effective treatments for pustular psoriasis that may work more rapidly and have fewer side effects. These are expected to be available in the next few years.

Pustular psoriasis flare-up in a patient with COVID-19

INTRODUCTION

The various cutaneous manifestations have lately appeared in the setting of COVID-19. Psoriasis flare-ups have been reported during a COVID-19 infection.

CASE PRESENTATION

We present a case of a 32-year-old woman with COVID-19 who presented with generalized pustular psoriasis. She received oral prednisolone, hydroxyzine, and topical clobetasol. The patient received follow-up two weeks later and found that her lesions were favorably desquamating.

METHODS

The PubMed, SCOPUS, and ISI Web of Science databases were thoroughly searched for English studies reporting psoriasis flare-ups following SARS-CoV-2 infection. Ten case reports/series were included after screening.

CONCLUSIONS

Our case report brings awareness to clinicians for the possible cutaneous manifestation of COVID-19, which should be considered part of the differential diagnoses.

Recalcitrant paradoxical pustular psoriasis induced by infliximab: Two case reports

BACKGROUND

Paradoxical psoriasis induced by tumor necrosis factor alpha antagonists is a rare side effect of those drugs and has similarities with and differences from classical psoriasis in clinical and pathological characteristics. Treating severe paradoxical psoriasis is challenging because the reported cases are rare, with treatment experience being only anecdotal.

CASE SUMMARY

We report 2 cases of paradoxical psoriasis caused by infliximab. Both cases manifested with a significant number of pustular lesions and had protracted and complicated clinical courses. In case 1, secukinumab alone could not control the eruptions, but colchicine supplementation markedly decreased disease activity. In case 2 miscellaneous medications were administered, including the systemic drug acitretin, the immunosuppressive drug cyclosporine, and the biologic agent ustekinumab. However, multiple applications of those medications failed to prevent new lesions from occurring. Both cases showed moderate-to-high anti-nuclear antibody titers.

CONCLUSION

Based on these cases, moderate-to-high anti-nuclear antibody titer seems to be a risk factor for paradoxical psoriasis. In addition, extensive pustular presentation may be a negative prognostic indicator and may portend a protracted clinical course refractory to therapy.

Are Systemic Corticosteroids Causing Psoriasis Flare-Ups? Questionnaire for Danish Dermatologists, Gastroenterologists and Rheumatologists

BACKGROUND

Psoriasis flare-ups and the change of morphology from nonpustular to pustular psoriasis following tapering and withdrawal of systemic corticosteroids have been reported. Despite these risks, systemic corticosteroids are still widely prescribed for patients with psoriasis, but the knowledge about psoriasis flare-ups and whether the physicians take precautions during these treatments is limited.

METHODS

We conducted a questionnaire study among all dermatologists, gastroenterologists and rheumatologists in Denmark who work at a hospital or in a private practice to investigate the use, opinion and experience with oral, intramuscular and intra-articular corticosteroids in the treatment of patients with psoriasis.

RESULTS

We received answers from a total of 248 physicians. Compared with oral and intramuscular corticosteroids, intra-articular corticosteroids were the most reported treatment in patients with psoriasis and only used by the rheumatologists. It was mainly the dermatologists and rheumatologists who had observed psoriasis flare-ups following treatment with oral, intramuscular and intra-articular corticosteroids. Half of the dermatologists (50%) and a fourth of the rheumatologists (29%) had observed at least one psoriasis flare-up following treatment with oral corticosteroids. About 10% of both the dermatologists and the rheumatologists had observed at least one psoriasis flare-up following treatment with intramuscular and/or intra-articular corticosteroids. Overall, 44% of the respondents took precautions, when they treated a patient with psoriasis with oral, intramuscular and intra-articular corticosteroids.

CONCLUSION

The results from the questionnaire indicate that systemic corticosteroids for patients with psoriasis can cause flare-ups and should be used with care.

"Autoinflammatory psoriasis"-genetics and biology of pustular psoriasis

Psoriasis is a chronic inflammatory skin condition that has a fairly wide range of clinical presentations. Plaque psoriasis, which is the most common manifestation of psoriasis, is located on one end of the spectrum, dominated by adaptive immune responses, whereas the rarer pustular psoriasis lies on the opposite end, dominated by innate and autoinflammatory immune responses. In recent years, genetic studies have identified six genetic variants that predispose to pustular psoriasis, and these have highlighted the role of IL-36 cytokines as central to pustular psoriasis pathogenesis. In this review, we discuss the presentation and clinical subtypes of pustular psoriasis, contribution of genetic predisposing variants, critical role of the IL-36 family of cytokines in disease pathophysiology, and treatment perspectives for pustular psoriasis. We further outline the application of appropriate mouse models for the study of pustular psoriasis and address the outstanding questions and issues related to our understanding of the mechanisms involved in pustular psoriasis.

Palmoplantar pustulosis: Current understanding of disease definition and pathomechanism

Pustulosis palmaris et plantaris, or palmoplantar pustulosis (PPP), is a chronic pustular dermatitis involving the palms and soles and is characterized by vesicles, pustules, erythema, lichenification, and abnormal desquamation. It is one of the most common skin diseases in Japan but its pathomechanism is unclear and the disease remains poorly defined. Consequently, adequate treatment for PPP is lacking. As a localized type of pustular psoriasis, PPP has long been treated with the conventional therapies used for plaque-type psoriasis, especially in Western countries. However, PPP may be a distinct entity, with a much lower prevalence in Western countries than in Japan. Furthermore, while treatment has yielded insights into the underlying pathology in plaque-type psoriasis, the pathogenesis of PPP has yet to be elucidated. In 2018, Gulselkumab, a monoclonal antibody against interleukin (IL)-23, was certified for use in Japan and is the first biologic effective in PPP both in Japanese and other patients. In this review, we summarize the current understanding of PPP, including the revised definition and possible pathomechanism. The information presented herein provides a more complete picture of PPP and may facilitate the development of improved treatment options.

Review of treatments for generalized pustular psoriasis

BACKGROUND

Generalized pustular psoriasis (GPP) is an uncommon variant of psoriasis that is characterized clinically by sterile pustule formation superimposed over inflamed, erythematous skin.

METHODS

In June 2019, we conducted a systematic search of the PubMed Medline database using the keywords 'pustular psoriasis' and 'treatment'.

RESULTS

First-line treatment for the condition consists of established therapies, such as acitretin, cyclosporine, methotrexate, and infliximab. Several medications targeting IL-17 or IL-23 have also emerged recently with drugs such as ixekizumab, secukinumab, brodalumab, guselkumab, and ustekinumab having shown some efficacy.

CONCLUSIONS

This review highlights the research in support of common treatments of GPP, including classically used medications and newer monoclonal antibodies, and addresses the continued need for high quality studies regarding treatments for this condition.

A small population, randomised, placebo-controlled trial to determine the efficacy of anakinra in the treatment of pustular psoriasis: study protocol for the APRICOT trial

Background

Palmoplantar pustulosis is a rare but painful and debilitating disease. It consistently ranks the highest of all psoriasis phenotypic variants in terms of symptoms and functional impairment. Management of plaque-type psoriasis has been revolutionised in the last 10 years with the advent of biologic therapies, but treatment options for pustular psoriasis remain profoundly limited. On the basis of mechanistic findings which suggest a key pathogenic role for interleukin (IL)-1 in pustular psoriasis, we hypothesise that anakinra (IL-1 blockade) will be an efficacious treatment for pustular psoriasis.

Methods/design

We will conduct a two-stage, adaptive, double-blind, randomised, placebo-controlled trial to test the hypothesis that anakinra, self-administered daily by subcutaneous injection over 8 weeks, will deliver therapeutic benefit in palmoplantar pustular psoriasis, a localised form of pustular psoriasis typically involving the palms and/or soles. Safety outcomes will be collected for 20 weeks. A total of 64 participants will be randomised to anakinra or placebo in a 1:1 ratio. At the end of stage 1, a decision to progress to stage 2 will be made. This decision will take place after 24 participants have been randomised and followed for 8 weeks and will be based on the ordering of the observed mean outcome values in both treatment arms. At the end of stage 1, the reliability of outcome measurements and method to collect the data will also be assessed, and the primary outcome will be confirmed for stage 2.

Discussion

We have undertaken an adaptive approach in which we will gain proof-of-concept data prior to completing a powered efficacy trial because pustular psoriasis is a rare disease, no validated outcome measures to detect change exist, and limited safety data for anakinra exist in this population. To our knowledge, this will be the first randomised controlled trial that will provide valuable evidence for the efficacy and safety of IL-1 blockade for treatment in pustular psoriasis.

Trial registration

ISRCTN13127147. Registered on 1st August 2016.

EudraCT, 2015-003600-23. Registered on 1st April 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2841-y) contains supplementary material, which is available to authorized users.

Acrodermatitis Continua of Hallopeau with Bone Resorption in an 8-Year-Old Patient: A Case Report

Acrodermatitis continua of Hallopeau (ACH) is an uncommon inflammatory disease manifesting as sterile pustular eruption of the fingers and toes. The disease is of a chronic relapsing nature and is often refractory to treatment. With longstanding disease, osteitis with consequent bone resorption of the underlying phalanges can occur, leading to disability. While the incidence of ACH is rare in children, complications like osteolysis have not been reported previously in this age group. In this paper, we report the case of an 8-year-old boy with severe ACH complicated by bone resorption.

The Efficacy of Biologic Therapy for the Management of Palmoplantar Psoriasis and Palmoplantar Pustulosis: A Systematic Review

Introduction

Palmoplantar psoriasis (PP) and palmoplantar pustulosis (PPP) are diseases affecting the hands and/or feet that can cause marked physical discomfort and functional disability. The tumor necrosis factor-alpha antagonists adalimumab, etanercept, and infliximab, the interleukin (IL)-17A inhibitors ixekizumab and secukinumab, and the IL-23 or IL-12/IL-23 inhibitors guselkumab and ustekinumab have been well studied for the treatment of moderate to severe plaque psoriasis. Less is known about the efficacy and safety of these agents for the treatment of PP (hyperkeratotic and pustular forms) and PPP. The aim of this review was to investigate the efficacy of biologic therapy for the treatment of hyperkeratotic PP, pustular PP, and PPP.

Methods

A systematic search of the medical electronic databases (Medline, Embase, and Cochrane Library) was conducted to identify studies or case reports which both used biologic therapy for the treatment of hyperkeratotic PP, pustular PP, and PPP and reported treatment outcomes.

Results

The systematic search identified 579 published articles, of which 44 were included in the analysis. Seven of the articles involved randomized placebo-controlled trials, two were open label trials, and the remaining were cohort studies, case series, or case reports. In the randomized controlled trials on the treatment of hyperkeratotic PP, adalimumab, guselkumab, infliximab, ixekizumab, and secukinumab each demonstrated superiority to placebo at 16, 16, 14, 12, and 12 or 16 weeks, respectively (p < 0.05). For the treatment of pustular PP, ustekinumab 45 mg was not superior to placebo at 12 and 16 weeks, respectively (p > 0.05), although an open label study demonstrated that four of five patients on a therapeutic regimen of ustekinumab 90 mg achieved clinical clearance at 16 weeks. For the treatment of PPP, etanercept and ustekinumab 45 mg were not superior to placebo at 12 and 16 weeks, respectively (p > 0.05). A combined analysis of studies for hyperkeratotic PP demonstrated that 94.7%, 90.0%, 82.5%, 89.1%, and 86.7% of patients experienced an improvement of at least 50% upon treatment with adalimumab, guselkumab, ixekizumab, secukinumab, and ustekinumab, respectively. In a combined analysis of case reports examining PPP, infliximab showed the greatest efficacy at 100.0% clinical improvement of patients from case reports, followed by ustekinumab at 58.8% clinical improvement. Few serious adverse events were reported, but several were reported in patients treated with infliximab or secukinumab.

Conclusion

Biologic therapy is effective and well-tolerated for the treatment of hyperkeratotic PP, but less data are available on the treatment of pustular PP or PPP. Adalimumab, guselkumab, ixekizumab, secukinumab, and ustekinumab all showed > 80% efficacy for the treatment of hyperkeratotic PP, while infliximab and ustekinumab showed moderate efficacy for the treatment of pustular PP, and infliximab was the most efficacious treatment for PPP.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-017-0207-0) contains supplementary material, which is available to authorized users.

Correlation of IL36RN mutation with different clinical features of pustular psoriasis in Chinese patients

Different studies have reported various values for the percentage of patients with IL36RN mutations, and it has also been reported that the sites of these mutations differ among different ethnicities. The current study was a cross-sectional study conducted to investigate the risk factors predicting IL36RN mutation in Chinese patients with different clinical features of pustular psoriasis. 57 Han Chinese patients, including 32 with generalized pustular psoriasis, 14 with palmoplantar pustulosis, 9 with plaque-type psoriasis with pustules, and 2 with erythrodermic psoriasis, were enrolled between March 2013 and July 2014. Blood samples were collected, genomic DNA was extracted from leukocytes, and polymerase chain reaction (PCR)-based Sanger sequencing was used to analyze the coding exons and flanking introns of the IL36RN gene. The patients with generalized pustular psoriasis exhibited the highest IL36RN mutation rate (75 %) among the aforementioned patient types, with the subgroup consisting of those patients who had features of acrodermatitis continua of Hallopeau exhibiting the highest c.115+6T>C mutation rate (93.8 %). In addition, early onset, ever generalized pustular psoriasis (more than two attacks), ever acrodermatitis continua of Hallopeau, inverse psoriasis, and a family history of pustular psoriasis were associated with IL36RN mutation. The c.115+6T>C mutation was the most common and the most important variant in all subtypes of pustular psoriasis with IL36RN mutations among our sample of Chinese patients.

A Case of Old Age-Onset Generalized Pustular Psoriasis with a Deficiency of IL-36RN (DITRA) Treated by Granulocyte and Monocyte Apheresis

A 78-year-old woman who had been suffering from psoriasis vulgaris for 31 years was admitted to hospital because of her erythroderma. A toxic eruption was suspected and she was treated with prednisolone 30 mg daily. However, it was ineffective and, suspecting psoriatic erythroderma, cyclosporine 150 mg daily was administered with tapering of the prednisolone. Two weeks after a dose reduction of cyclosporine to 100 mg/day, erythroderma with widespread generalized pustules and fever developed. Histology of a biopsy revealed inflammatory infiltrates in the skin with a spongiform pustule of Kogoj, which was consistent with generalized pustular psoriasis (GPP). Her pustules improved with additional etretinate 20 mg/day, but the erythroderma persisted and she consulted us. Three sessions of granulocyte and monocyte apheresis once weekly were effective for her condition and decreased her serum levels of IL-6 and IL-8. She had homozygous mutations of c.[28C>T] in IL36RN which cause p.[Arg10Ter]. She is the oldest reported case of GPP with a deficiency of interleukin-36 receptor antagonist (DITRA), although GPP in DITRA has been suggested to usually occur in younger cases with no pre-existing psoriasis vulgaris.

Autoinflammatory pustular neutrophilic diseases

This article provides a new categorization of inflammatory pustular dermatoses in the context of recent genetic and biological insights. Monogenic diseases with pustular phenotypes are discussed, including deficiency of interleukin 1 receptor antagonist, deficiency of the interleukin 36 receptor antagonist, CARD14-associated pustular psoriasis, and pyogenic arthritis, pyoderma gangrenosum, and acne. How these new genetic advancements may inform how previously described pustular diseases are viewed, including pustular psoriasis and its clinical variants, with a focus on historical classification by clinical phenotype, is also discussed.

A Case of Tumor Necrosis Factor-alpha Inhibitors-induced Pustular Psoriasis

Anti-tumor necrosis factor (TNF)-alpha agents promise better disease control for the treatment of ankylosing spondylitis resistant to classical disease-modifying treatments. Etanercept, a recombinant human TNF receptor fusion protein, is used to treat a variety of TNF-alpha-mediated diseases by inhibiting the biological activity of TNF-alpha. We experienced a case of pustular psoriasis in a 32-year-old man during anti-TNF-alpha therapy with etanercept. He had a history of ankylosing spondylitis for 2 years. Two years after treatment of etanercept, erythematous pustules developed on his palms and soles. He had no previous history of pustular psoriasis. The skin lesion improved as the etanercept therapy was stopped, but pustular skin eruption recurred as adalimumab, a different TNF-alpha inhibitor, was administered to manage his ankylosing spondylitis. Several TNF-alpha inhibitors have different molecular structures, but these inhibitors might have a similar potency to induce pustular psoriasis from this case.