Presented by: Jaryd Freedman, MD and Carrie Ann Cusack, MD
Drexel University College of Medicine
May 16, 2016
Erythrodermic psoriasis (EP) is a severe form of psoriasis with erythema involving greater than 75% of body surface area. It may present acutely or can arise more insidiously and follow a chronic course. Patients with EP are at increased risk of severe morbidity and mortality. In its acute forms patients may be at risk of dehydration, electrolyte imbalance, and severe skin infections, so hospitalization may be considered. EP must be differentiated from other causes of erythroderma, namely drug-induced eruptions, cutaneous T-cell lymphoma, and other primary dermatoses.
While there are few well-controlled clinical trials regarding the treatment of EP, generally the goal is to bring the disease under rapid control, typically with cyclosporine or infliximab. In less acute cases either methotrexate or acitretin can be tried. More recent literature suggests that many of the newer biologic therapies in addition to infliximab are effective to bring EP under control. While the patient is acutely erythrodermic it is advisable to avoid phototherapy due to the risk of UV-induced erythroderma and the risk of a Koebnerization-like response. After control is achieved the patient can be transitioned to a traditional systemic maintenance therapy.
Controlling EP with biologic therapy can prove difficult. Viguier et al reported that only one third of erythrodermic psoriasis patients were on the same biologic agent one year after starting therapy, with a majority of these patients citing lack of efficacy as the reason for discontinuation. One explanation for the lack of sustained efficacy of biologic therapies is the induction of anti-drug antibodies (ADAb). It has been shown that ADAb’s can significantly reduce the efficacy of both infliximab and adalimumab. The production of the ADAb can be attenuated with concomitant use of methotrexate or other immunosuppresants. In addition, if a biologic treatment becomes ineffective, switching to a different biologic agent can be effective. EP can prove difficult to control despite the plethora of systemic treatments now available for psoriasis.
Psoriasis is not just a disease of the skin but a chronic systemic inflammatory disease associated with multiple medical comorbidities including but not limited to cardiovascular disease, cerebrovascular disease, diabetes mellitus, metabolic syndrome, chronic obstructive pulmonary disease, asthma, peptic ulcer disease, liver disease, renal failure, rheumatoid arthritis, and cancer. The risk of significant medical comorbidities in patients with psoriasis is directly correlated with the extent of skin involvement. Chronic EP patients are at very high risk of significant medical comorbidities which must be considered when choosing treatment regimens for these patients.
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