Treatment of erythrodermic psoriasis

with biologics: A systematic review

Osward Y. Carrasquillo, MD, MPH,a Gabriela Pab
on-Cartagena, MD,b Leyre A. Falto-Aizpurua, MD,a
Marely Santiago-V
azquez, MD, Karina J. Cancel-Artau, BS,c Gabriel Arias-Berrios, MD,a and
a

Rafael F. Mart
ın-Garc
ıa, MDa

San Juan, Puerto Rico

Background: Biologic medications for plaque psoriasis have been used to treat erythrodermic psoriasis
(EP). Since the guidelines for management of EP were published, new biologic medications have been
approved for the treatment of plaque psoriasis.

Objective: To analyze the evidence of biologic medications in the treatment of EP based on response and
tolerability.

Methods: A comprehensive search was conducted with the PubMed, Cochrane Library, Embase, and
Scopus databases through December 31, 2018. Studies reporting 1 or more cases of EP, defined as
[75% body surface area involvement, in patients aged $18 years treated with biologics were included.
Baseline Psoriasis Area and Severity Index score, score improvement, and adverse events
were documented. Adequate response to treatment was defined as Psoriasis Area and Severity Index
$50.

Results: Included were 43 articles, yielding a total of 179 patients. Most patients responded at some point
during treatment, with a higher level of evidence for infliximab, ustekinumab, ixekizumab, and
guselkumab. Infection was the most common adverse event (n = 35).

Limitations: Data are limited to case reports, case series, and uncontrolled studies.

Conclusion: Patients with EP treated with biologics demonstrated positive responses and treatment was
well-tolerated, with a weak recommendation and limited quality of evidence in favor of infliximab,
ustekinumab, ixekizumab, and guselkumab. ( J Am Acad Dermatol 2020;83:151-8.)

Key words: adalimumab; biologics; erythrodermic psoriasis; etanercept; golimumab; guselkumab;

infliximab; ixekizumab; psoriasis; secukinumab; ustekinumab.

P soriasis is a chronic inflammatory condition of may trigger EP are abrupt withdrawal of systemic
the skin affecting approximately 2% of the medications such as corticosteroids, drug reactions
world’s population.1 Several clinically distinct to medications such as lithium, and underlying
subtypes of psoriasis include chronic plaque psori- systemic infections.4 EP is characterized by general-
asis, nail psoriasis, pustular psoriasis, erythrodermic ized erythema and scaling affecting more than 75% of
psoriasis (EP), and guttate psoriasis.2 EP is a rare and body surface area.3,5 Affected patients can present
severe variant with a prevalence of less than 3% of all numerous systemic symptoms such as fever, tachy-
cases.3 This condition generally develops in patients cardia, lymphadenopathy, arthralgia, and fatigue.5
with poorly controlled psoriasis. Other factors that Without appropriate treatment, high-output cardiac

From the Department of Dermatologya and the Transitional Year Correspondence to: Osward Y. Carrasquillo, MD, MPH, University
Program,b University of Puerto Rico School of Medicine; and of Puerto Rico School of Medicine, Department of
the University of Puerto Rico School of Medicine, San Juan.c Dermatology, PO Box 365067, San Juan, PR 00936-5067.
Funding sources: None. E-mail: [email protected].
Conflicts of interest: None disclosed. Published online April 2, 2020.
IRB approval status: Not necessary for this systematic review due 0190-9622/$36.00
to all the data being taken from public, anonymous literature. Ó 2020 by the American Academy of Dermatology, Inc.
Accepted for publication March 25, 2020. https://doi.org/10.1016/j.jaad.2020.03.073
Reprints are not available from the authors.

151

Downloaded for ABDUL HAMEED ([email protected]) at ClinicalKey Global Guest Users from ClinicalKey.com by Elsevier on June 25, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
152 Carrasquillo et al J AM ACAD DERMATOL
JULY 2020

failure, malabsorption, anemia, and sepsis could review protocol is registered with PROSPERO
occur, resulting in increased morbidity, and in (CRD42019133413; https://www.crd.york.ac.uk/
some cases, death.2,3 prospero/).
Treatment can be very challenging. The latest
National Psoriasis Foundation Consensus Guidelines Study eligibility, selection criteria, and
recommend cyclosporine or infliximab as first-line screening
therapy due to their rapid onset of action. Independent assessment of the titles and abstracts
Other recommended first-line agents include was performed out inde-
acitretin and methotrexate.6 pendently by 2 of the
However, these recommen- authors (O.Y.C. and K.J.C.).
CAPSULE SUMMARY
dations were made before Disagreements were resolved
evidence of efficacy and through discussion with a
safety in the treatment of Biologic medications have been
d
third author (R.F.M.). All
EP was available for most demonstrated to have a positive studies reporting 1 or more
biologic agents recently response in the treatment of cases of EP treated with bi-
approved to treat psoriasis. erythrodermic psoriasis. ologics were included. EP was
Levin et al7 reviewed the Infliximab, ustekinumab, guselkumab,
d
defined as [75% of body sur-
safety and efficacy of usteki- and ixekizumab should be considered face area involvement with
numab, adalimumab, etaner- first-line biologic agents in the treatment inflammatory erythema and
cept, and infliximab in the of acute and severe flares of scaling at baseline. The
treatment of EP. Since then, erythrodermic psoriasis, whereas following criteria were used
additional biologic medica- etanercept and adalimumab should be to exclude articles: pediatric
tions, such as ixekizumab, considered as second-line agents. patients (\18 years), \75% of
secukinumab, and guselku- body surface area involve-
mab, have been approved ment, erythroderma caused
for the treatment of moderate to severe plaque by a condition other than psoriasis, patient was treated
psoriasis. with biologics for a different condition that was not EP,
In this study, we perform a systematic review to or article failed to mention response to treatment. If the
determine the response and tolerability of biologic full text was not available online, it was ordered at the
medications used in the treatment of EP, including University of Puerto Rico School of Medicine library.
adalimumab, etanercept, infliximab, ixekizumab,
golimumab, guselkumab, secukinumab, and usteki- Data extraction and statistical analysis
numab, and make treatment recommendations The following variables were gathered as
based on level of evidence, onset of action, adverse available: age, sex, body mass index, duration of
effects, and sustained response with these disease, comorbidities, prior therapies, adjuvant
medications. treatments, Psoriasis Area and Severity Index (PASI)
score, total follow-up time, PASI score improvement,
MATERIALS AND METHODS and adverse events (AEs). Adequate response to
Search strategy treatment was defined as PASI $50. Statistical
This review was performed in accordance with analysis was done using IBM SPSS 25 software
the Preferred Reporting Items for Systematic Reviews (IBM, Armonk, NY).
and Meta-Analyses.8 A primary literature search was
conducted with the databases PubMed, Scopus, Risk of bias, level of evidence, and grade of
Embase, and Cochrane Library. We identified eligible recommendation assessment
articles from database inception to December 31, Owing to the nature of the condition, we did not
2018. The search terms were ‘‘biologics’’ and expect to find comparative studies. To assess the risk
‘‘erythrodermic psoriasis,’’ ‘‘biologic’’ and ‘‘erythro- of bias of studies, we used a tool developed by Haffar
dermic psoriasis,’’ ‘‘(drug name)’’ and ‘‘erythroder- et al9 derived from the Newcastle Ottawa scale.10
mic psoriasis.’’ Drug names included secukinumab, This tool has been used previously.9,11-14 It consists
ixekizumab, golimumab, guselkumab, infliximab, of 5 criteria in the form of questions with a binary
etanercept, ustekinumab, and adalimumab. Articles response (yes/no) to indicate whether the item is
written in Spanish and English were included. suggestive of bias. The tool is composed of the
There were no limitations on article type. After the following questions:
selection process, the references of all included 1. Did the patient(s) represent the whole case(s)
articles were assessed for missing publications. The of the medical center?

Downloaded for ABDUL HAMEED ([email protected]) at ClinicalKey Global Guest Users from ClinicalKey.com by Elsevier on June 25, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
J AM ACAD DERMATOL Carrasquillo et al 153
VOLUME 83, NUMBER 1

could not be extracted.57 Supplemental Table I

Abbreviations used:
(available via Mendeley at https://doi.org/10.
AE: Adverse event 17632/dk7f9m4jbc.2) provides a summary of the
EP: erythrodermic psoriasis
PASI: Psoriasis Area and Severity Index studies where EP was treated with biologics and
the risk of bias assessment.

Efficacy
2. Was the diagnosis correctly made? Most patients showed adequate response in their
3. Were other important diagnoses excluded? condition at some point during treatment interven-
4. Were all important data cited in the report? tion. Of 122 patients that reported PASI scores after
5. Was the outcome correctly ascertained? treatment with biologics, 9.0% of patients failed to
Quality of the report was considered good (low achieve PASI 50.26,34,39,46 In a multicenter retrospec-
risk of bias) when all 5 criteria were fulfilled, tive study with multiple biologics, Viguier et al57
moderate (moderate risk of bias) when 4 were reported PASI 75 at 10 to 14 weeks in 40% of those
fulfilled, and poor (high risk of bias) when #3 treated with infliximab and equal improvement in
were fulfilled. Two of the authors (O.Y.C. and G.P.) 67%, 67%, and 0% of patients treated with etanercept,
assessed the risk of bias of the studies with adalimumab, and ustekinumab, respectively. A
discussion with a third author (R.F.M.) in case of smaller proportion of patients maintained PASI 75
disagreement. at weeks 22 to 24 (infliximab, 20%; etanercept, 50%;
Recommendations for each biologic were given and adalimumab, 60%). Below we provide a
based on criteria by Robinson and colleagues.15 summary of the efficacy of each biologic medication
in the treatment of EP based on reduction of PASI
score. The study by Viguier et al57 was excluded from
RESULTS the following analysis because they reported flares
Systematic search results instead of patients, and thus, we were unable to
We included 43 articles yielding 179 patients with extract the individual data from the study.
EP treated with biologic medications (Fig 1). Case Recommendations for each biologic are provided
reports comprised 65.1% of the articles, followed by in Table II.16-58
case series (14.0%) and open-label studies (11.6%). Secukinumab. Of 19 patients who were admin-
There were 3 retrospective studies and 1 open istered secukinumab, 16 responded to treatment,
prospective study. Sixteen articles reported treat- and 4 of 8 patients who reported improvement
ment with infliximab,16-31 10 with ustekinumab,32-41 between weeks 2 and 6 achieved PASI 75.47-49 One
4 with etanercept,42-45 5 with secukinumab,46-50 and of these patients demonstrated continuous improve-
3 with adalimumab.51-53 Ixekizumab,54 golimu- ment and reached PASI 100 by weeks 8 to 12. Two
mab,55 and guselkumab56 were each found in 1 additional patients showed PASI 100 within this time
study. One article reported patients treated with frame.47,50 Mateu-Puchades et al48 also reported PASI
infliximab, adalimumab, etanercept, or ustekinu- scores during weeks 16 to 20, with 5 of 5 patients
mab, and another article reported patients treated reaching PASI 90. Weng et al46 described that 70% of
with infliximab or etanercept.57,58 patients responded to treatment, showing evident
clearing of psoriasis (PASI[ 75) by week 16. One of
Description of patients these patients experienced relapse by week 24. Two
The mean age at presentation was 46.4 years, with patients demonstrated a sustained response after
a male-to-female ratio of 3.6:1. Table I summarizes approximately 6 months.46
the baseline characteristics of patients. An Infliximab. Forty-one patients were treated
assessment of all of the selected articles showed with infliximab. No PASI score was reported for
the most common medications reported were 17 patients, but marked improvement of erythro-
ustekinumab and infliximab, with 54 and 41 patients, derma was described 2 weeks after infliximab
respectively.16-41,58 They were followed by infusion.20,22-25,31 One patient evaluated using a
secukinumab (n = 19), etanercept (n = 14), guselku- modified PASI score achieved a significant
mab (n = 11), ixekizumab (n = 8), adalimumab response.18 In a study by Torii et al,27 8 patients
(n = 3), and golimumab (n = 1).42-56,58 One article were treated with infliximab, and the median PASI
described 42 flares in 28 patients treated with improvement reported was 67.9% at week 10. Thus,
multiple biologic agents (infliximab, adalimumab, we were unable to assess whether any patient
etanercept, and ustekinumab) but was not included from the that study did not respond to therapy.
in the analysis because data for individual patients Arroyo-Tridico et al17 reported a patient who

Downloaded for ABDUL HAMEED ([email protected]) at ClinicalKey Global Guest Users from ClinicalKey.com by Elsevier on June 25, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
154 Carrasquillo et al J AM ACAD DERMATOL
JULY 2020

Fig 1. Study selection flow diagram.

Table I. Baseline characteristics of patients with Etanercept. Fourteen patients were treated with
erythrodermic psoriasis treated with biologic etanercept. One patient did not report PASI scores
medications but described significant improvement; neverthe-
Total reported
less, this patient relapsed during therapy.42 PASI
Characteristic patients, No. Value scores for 12 patients were reported on weeks 8 to
Age at presentation, mean y 174 46.4 12: 7 achieved PASI $75, 3 achieved PASI 50, and 2
Psoriasis duration, mean y 140 17.2 did not respond.44,45,58 Romero-Mate et al43 reported
Male sex, No. (%) 171 134 (78.4) a patient with PASI 100 over 34 months.
Body mass index, mean kg/cm2 68 24.8 Ustekinumab. Fifty-four patients were adminis-
Baseline PASI score, mean 152 40.5 tered ustekinumab, and 16 reported PASI score
Total follow-up, mean mo 135 12.3 improvement at weeks 2 to 6. Although 8 of these
patients were not responsive during that time frame,
PASI, Psoriasis Area and Severity Index.
all except 1 of the patients eventually responded to
therapy.32,33,38-40 There were 44 of 46 patients
with PASI $50 16 to 24 weeks after starting
maintained PASI 100 for 11 years. Another study medication.33-36,39,41 One patient did not respond
reported more than 90% improvement at week 6 in to treatment, and another patient initially responded
all 7 patients but did not specify which instrument but relapsed 28 weeks after intervention.39,41
was used to measure this response.19 Six other Another patient reported PASI $90 at week 114 of
studies reported significant improvement in 10 treatment.37 Only 7.4% of patients failed to respond
patients by weeks 2 to 12 (PASI $75).16,21,28-30,58 to treatment.34,39,41
Poulalhon et al26 reported PASI score-based Ixekizumab. Eight patients were treated with
outcomes by week 14: 3 patients achieved PASI ixekizumab as part of an open-label study. By
$75 and 2 patients did not respond.26 week 12, all patients achieved PASI 75, 5 of 8
Adalimumab. Only 3 patients received adalimu- achieved PASI 90, and 2 of 8 achieved PASI 100. By
mab for EP. One patient showed remission at week 3 week 24, 100% of patients reached PASI 75, 7 of 8
and the other 2 at week 12. PASI scores were not reached PASI 90, and 1 of 8 reached PASI 100. PASI
reported.51-53 scores were sustained by week 52.54

Downloaded for ABDUL HAMEED ([email protected]) at ClinicalKey Global Guest Users from ClinicalKey.com by Elsevier on June 25, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
J AM ACAD DERMATOL Carrasquillo et al 155
VOLUME 83, NUMBER 1

Table II. Assessment of level of evidence and grade of recommendation by biologic medication
Level of Grade of
Biologic evidence recommendation Source
Secukinumab 4 2B Weng et al,46 Mateu-Puchades et al,48 Mugheddu et al47
5 2B Galluzzo et al,49 Rongioletti et al50
Ustekinumab 3 2A Pescitelli et al34
4 2B Wang et al,39 Concha-Garzo
n et al41
5 2B Saraceno et al, Stinco et al,33 Kim et al,35 Koutsoukou et al,36
32

Castin~eiras et al,37 Santos-Juanes et al,38 Errichetti et al40

Infliximab 5 2B Arroyo-Tridico et al,17 Rongioletti et al,18 Takahashi et al,19 Lisby et al,20
O’Quinn et al,22 Fiehn et al,23 Lewis et al,24 Kurokawa et al,28
Belinchon et al,29 Yip et al,30 Su
arez Pedreira et al,31 Sahel et al58
4 2B Yip et al,21 Heikkil€a et al25
3 2A Valdes et al,16 Poulalhon et al,26 Torii et al27
Ixekizumab 3 2A Saeki et al54
Adalimumab 5 2B Mumoli et al,51 Richetta et al,52 Vidal et al53
Etanercept 5 2B Talat et al,42 Romero-Mat
e et al,43 Pique-Duran et al,45 Sahel et al58
44
3 2A Esposito et al
Golimumab 5 2B Won-Ku Lee et al55
Guselkumab 3 2A Sano et al56
Multiple biologics 3 2A Viguier et al57

Golimumab. One patient was treated with goli- the important role of interleukin (IL) 12 and IL-23
mumab and responded to treatment by week 4 and inflammatory pathways in the pathogenesis of EP.33
continued to improve with PASI $75 by week 12.55 As reported by Stinco et al,33 ustekinumab seems to
Guselkumab. Guselkumab was reported in 11 be a promising candidate for the long-term control of
patients and all responded. By week 8, all patients EP, especially when taking into consideration the
achieved PASI [50. At 52 weeks after treatment, 10 well-known possibility of developing tachyphylaxis
patients demonstrated sustained responses (mean while on infliximab.7
PASI $75), and 1 patient was lost to follow-up.56 The second most common biologic used was
infliximab, demonstrating excellent efficacy with
Safety few serious AEs that cannot be fully attributed to
There were 60 AEs (37.3%) reported secondary to the medication. The drug had a rapid onset of
biologic therapy among studies that recorded their action, with responses achieved as early as 48 hours
occurrence. Infectious events (35 of 60) were after initiation of treatment.22,24 Most patients
the most common. Further details can be found in demonstrated sustained improvement after 6 to
Table III. 10 weeks.17,20,21,26-28 Infliximab was used in
combination with methotrexate or acitretin in several
DISCUSSION studies, but these patients failed to respond faster
We aim to update the recommendations for than those on monotherapy.17,19-21,25,27 For these
treating EP with biologics published by Levin et al7 reasons, we agree with Rosenbach et al6 and Levin
in 2012. Since their publication, new biologics have et al,7 who suggested that infliximab should be
been approved for the treatment of plaque psoriasis. considered a first-line therapeutic agent in the
There is a lack of randomized, double-blind, treatment of patients with acute, severe, or unstable
controlled trials and head-to-head comparisons. EP.6
Therefore, recommending any of the biologics as a Secukinumab, an IL-17A inhibitor, was adminis-
first-line treatment for the management of EP is a tered to 19 patients, of whom 84.2% showed
challenge. Recommendations for each biologic are improvement by $8 weeks with no significant
presented in Table II. Overall, ustekinumab was the AEs.46-48,50 However, 31.6% of patients suffered a
most frequent biologic reported. It demonstrated a relapse. Weng et al46 attributed these recurrences to
slower onset of action than infliximab. Nevertheless, history of prior biologic failure in their patients.
patients treated with this medication reported long- Although this may be a possibility, a proportion of
term clinical improvement (follow-up period range, the patients responsive to such agents had also
3-29 months) with few AEs. These findings support been previously treated with alternate biologic

Downloaded for ABDUL HAMEED ([email protected]) at ClinicalKey Global Guest Users from ClinicalKey.com by Elsevier on June 25, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
156 Carrasquillo et al J AM ACAD DERMATOL
JULY 2020

Table III. Adverse effects reported in patients treated with biologics for erythrodermic psoriasis
Biologic Adverse event descriptions (n)
Secukinumab Hair repigmentation (1)
Ustekinumab Sudden death (1), furunculosis (1), widespread skin Staphylococcus aureus colonization (1), widespread
Staphylococcus epidermidis colonization (1), pulmonary miliary tuberculosis (1)
Infliximab ANA 1 serology (6), nasopharyngitis (3), infusion reaction (1), anaphylaxis (1) malaise (1), ductal cell
carcinoma (1), increased blood pressure (1), abnormal liver function test results (2), depression with
suicide attempt (1), sepsis secondary to Staphylococcus aureus (1), erysipelas (1), myocardial infarction
(1)
Ixekizumab Infection (6), hypersensitivity reaction (2), hepatic steatosis (1)
Adalimumab Unclassified T-cell lymphoma (1)
Etanercept Folliculitis (1), sepsis secondary to furunculosis (1), URTI (1), pruritus (1), UTI (1), pneumonia (1),
Staphylococcus aureus septicemia (1)
Golimumab None
Guselkumab Treatment-emergent infections (9), nasopharyngitis (4), gastroenteritis (1), nausea (1), arthralgia (1), rib
fracture (1)

ANA, Antinuclear antibody; URTI, upper respiratory tract infection; UTI, urinary tract infection.

medications. This implies that another mechanism suggested therapies, it is important to treat every
could be responsible for relapses after treatment patient on an individual basis.
with secukinumab. Given its high relapse rate, we
recommend using secukinumab as second-line CONCLUSION
therapy for EP based on individual patient Biologic therapy in patients with EP seems to be
characteristics. well-tolerated and demonstrated a positive
Most patients treated with etanercept and adali- response. Recommendations for biologic agent
mumab responded to therapy. Nevertheless, it is therapy in EP are based on limited evidence. We
important to mention that 21 and 18 patients, recommend infliximab or ustekinumab in acute,
respectively, who received other biologics reported severe cases of EP as first-line biologic agents. IL-23
prior failure to etanercept or adalimumab. and IL-17 inhibitor agents seem to be a promising
Etanercept was discontinued in some patients mainly category of biologic treatment of EP and can also be
due to its lack of efficacy and AEs.44,57 Consequently, considered as first-line therapy based on their level
we recommend considering etanercept and of evidence. Etanercept and adalimumab can be
adalimumab as second-line treatments for EP. used in milder, biologically na€ıve patients. Therapy
Guselkumab (IL-23 inhibitor) and ixekizumab for patients with EP should be individualized and
(IL-17 inhibitor) achieved significant improvement based on each patient’s disease characteristics,
after 52 weeks of follow-up.54 Minor infections were history of previous therapies, and comorbidities.
a common AEs of both medications. However, it is Increased understanding of pathogenic mechanisms
important to note that these studies had longer in EP and the continued development of newer
follow-up periods compared with most case reports biologic agents for the treatment of psoriasis will
and case series that reported the response of other contribute to improve the quality of life in these
biologics. Because of their level of evidence, seriously affected patients.
guselkumab and ixekizumab can both be considered
first-line treatments for EP. REFERENCES
Regardless of which medication is eventually 1. Christophers E. Psoriasisdepidemiology and clinical spectrum.
selected for the treatment of EP, adjuvant measures, Clin Exp Dermatol. 2001;26(4):314-320.
including medium-potency topical steroids, moistur- 2. Ladizinski B, Lee KC, Wilmer E, Alavi A, Mistry N, Sibbald RG. A
review of the clinical variants and the management of
izers, wet dressings, oatmeal baths, and continued psoriasis. Adv Skin Wound Care. 2013;26(6):271-284.
supportive care are important.6 3. Lebwohl M. Psoriasis. Lancet. 2003;361:1197-1204.
Unfortunately, data are limited to case reports, 4. Raychaudhuri SK, Maverakis E, Raychaudhuri SP. Diagnosis and
case series, and uncontrolled studies. This could classification of psoriasis. Autoimmun Rev. 2014;13(4-5):490-495.
5. Singh RK, Lee KM, Ucmak D, et al. Erythrodermic psoriasis:
contribute to publication bias, as evidenced by the
pathophysiology and current treatment perspectives. Psoriasis
risk of bias assessment in which most studies had a (Auckl). 2016;6:93-104.
moderate risk of bias. Furthermore, recommending a 6. Rosenbach M, Hsu S, Korman NJ, et al. Treatment of
specific medication is difficult, and despite the erythrodermic psoriasis: from the medical board of the

Downloaded for ABDUL HAMEED ([email protected]) at ClinicalKey Global Guest Users from ClinicalKey.com by Elsevier on June 25, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
J AM ACAD DERMATOL Carrasquillo et al 157
VOLUME 83, NUMBER 1

National Psoriasis Foundation. J Am Acad Dermatol. 2010;62(4): 24. Lewis TG, Tuchinda C, Lim HW, Wong HK. Life-threatening
655-662. pustular and erythrodermic psoriasis responding to infliximab.
7. Levin EC, Debbaneh M, Koo J, Liao W. Biologic therapy in J Drugs Dermatol. 2006;5(6):546-548.
erythrodermic and pustular psoriasis. J Drugs Dermatol. 2014; 25. Heikkil€a H, Ranki A, Cajanus S, Karvonen SL. Infliximab com-
13(3):342-354. bined with methotrexate as long-term treatment for eryth-
8. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting rodermic psoriasis. Arch Dermatol. 2005;141(12):1607-1610.
items for systematic reviews and meta-analyses: the PRISMA 26. Poulalhon N, Begon E, Lebb
e C, et al. A follow-up study in 28
statement. Open Med. 2009;3:e123-e130. patients treated with infliximab for severe recalcitrant psori-
9. Haffar S, Bazerbachi F, Prokop L, Watt KD, Murad MH, Chari ST. asis: evidence for efficacy and high incidence of biological
Frequency and prognosis of acute pancreatitis associated with autoimmunity. Br J Dermatol. 2007;156(2):329-336.
fulminant or non-fulminant acute hepatitis A: a systematic 27. Torii H, Nakagawa H. Long-term study of infliximab in
review. Pancreatology. 2017;17(2):166-175. Japanese patients with plaque psoriasis, psoriatic arthritis,
10. Wells G, Shea B, O’Connell D, et al. The Newcastle-Ottawa scale pustular psoriasis and psoriatic erythroderma. J Dermatol.
(NOS) for assessing the quality of nonrandomized studies in 2011;38(4):321-334.
meta-analysis. Ottawa, Ontario: The Ottawa Health Research 28. Kurokawa R, Hagiwara A, Niijima Y, Kojima K. Computed
Institute, 2011. tomography imaging findings in erythrodermic psoriasis
11. Bazerbachi F, Haffar S, Szarka LA, et al. Secretory diarrhea and treated with infliximab: a case report. Radiol Case Rep. 2018;
hypokalemia associated with colonic pseudo-obstruction: a 13(2):460-463.
case study and systematic analysis of the literature. 29. Belinchon I, Lucas A, Ballester I, Betlloch I, P
erez-Crespo M.
Neurogastroenterol Motil. 2017;29(11). Successful treatment of life-threatening erythrodermic psori-
12. Bazerbachi F, Sawas T, Vargas EJ, et al. Metal stents versus asis with infliximab. J Am Acad Dermatol. 2009;60(3):AB171.
plastic stents for the management of pancreatic walled-off 30. Yip L, Harrison S, Foley P. Infliximab rescue of efalizumab
necrosis: a systematic review and meta-analysis. Gastrointest withdrawal flare and psoriasis-precipitated depression. Aus-
Endosc. 2018;87(1):30-42. tralas J Dermatol. 2008;49(4):250-251.
13. Bazerbachi F, Leise MD, Watt KD, Murad MH, Prokop LJ, 31. Su
arez Pedreira I, Santos Juanes J, Caminal Montero L,
Haffar S. Systematic review of mixed cryoglobulinemia Trapiella L. Infliximab: an alternative in refractory erythroder-
associated with hepatitis E virus infection: association or mic psoriasis. Piel. 2006;21(6):317-318.
causation? Gastroenterol Rep. 2017;5:178-184. 32. Saraceno R, Talamonti M, Galluzzo M, Chiricozzi A, Costanzo A,
14. Bazerbachi F, Haffar S, Hussain MT, et al. Systematic review of Chimenti S. Ustekinumab treatment of erythrodermic psoriasis
acute pancreatitis associated with interferon-a or pegylated occurring after physical stress: a report of two cases. Case Rep
interferon-a: possible or definitive causation? Pancreatology. Dermatol. 2013;5(3):254-259.
2018;18(7):691-699. 33. Stinco G, Piccirillo A, Errichetti E, Bergamo S, Patrone P.
15. Robinson JK, Dellavalle RP, Bigby M, Callen JP. Systematic Treatment of recalcitrant erythrodermic psoriasis with usteki-
reviews: grading recommendations and evidence quality. Arch numab. Eur J Dermatol. 2014;24(3):387-390.
Dermatol. 2008;144(1):97-99. 34. Pescitelli L, Dini V, Gisondi P, et al. Erythrodermic psoriasis
16. Mar
ıa Del Pilar Vald
es A, Francisca Schroeder H, Vicky treated with ustekinumab: an Italian multicenter retrospective
Roizen G, Juan Honeyman M, Leonardo S
anchez M. Efficacy analysis. J Dermatol Sci. 2015;78(2):149-151.
of infliximab in patients with moderate and severe psoriasis 35. Kim YS, Kim HJ, Lee S, Park YL. Erythrodermic psoriasis
treated with infliximab (Remicade) [in Spanish]. Rev Med Chil. improved by ustekinumab: a report of two cases. Ann
2006;134(3):326-331. Dermatol. 2016;28(1):121-122.
17. Arroyo-Tr
ıdico L, Antonio JR, Mathias CE, Pozetti EMO. 36. Koutsoukou XA, Papadavid E, Theodoropoulos K,
Effectiveness and safety of infliximab for 11 years in a patient Rigopoulos D. Ustekinumab in severe complicated erythro-
with erythrodermic psoriasis and psoriatic arthritis. An Bras dermic psoriasis: rapid clearing, safety, and sustained remis-
Dermatol. 2017;92(5):743-745. sion. Dermatol Ther. 2014;27(5):257-259.
18. Rongioletti F, Borenstein M, Kirsner R, Kerdel F. Erythrodermic, 37. Casti~neiras I, Fern
andez-Diaz L, Ju
arez Y, Lueiro M. Sustained
recalcitrant psoriasis: clinical resolution with infliximab. J efficacy of ustekinumab in refractory erythrodermic psoriasis
Dermatolog Treat. 2003;14(4):222-225. after failure of antitumor necrosis factor therapies. J Dermatol.
19. Takahashi MD, Castro LG, Romiti R. Infliximab, as sole or 2012;39(8):730-731.
combined therapy, induces rapid clearing of erythrodermic 38. Santos-Juanes J, Coto-Segura P, Mas-Vidal A, Galache Osuna C.
psoriasis. Br J Dermatol. 2007;157(4):828-831. Ustekinumab induces rapid clearing of erythrodermic psoriasis
20. Lisby S, Gniadecki R. Infliximab (Remicade) for acute, severe after failure of antitumour necrosis factor therapies. Br J
pustular and erythrodermic psoriasis. Acta Derm Venereol. Dermatol. 2010;162(5):1144-1146.
2004;85(3):247-248. 39. Wang TS, Tsai TF. Clinical experience of ustekinumab in the
21. Yip L, Harrison S, Foley P. From biologic to biologic to biologic: treatment of erythrodermic psoriasis: a case series. J Dermatol.
lessons to learn for erythrodermic and recalcitrant 2011;38(11):1096-1099.
chronic plaque psoriasis. Australas J Dermatol. 2008;49(3): 40. Errichetti E, Piccirillo A. Latent tuberculosis reactivation in a
152-155. patient with erythrodermic psoriasis under treatment with
22. O’Quinn RP, Miller JL. The effectiveness of tumor necrosis ustekinumab and a low dose steroid, despite isoniazid
factor alpha antibody (infliximab) in treating recalcitrant chemoprophylaxis. Eur J Dermatol. 2014;24(4):508-509.
psoriasis: a report of 2 cases. Arch Dermatol. 2002;138(5):644- 41. Concha-Garz
on MJ, Godoy-Trapero A, Daud
en E, et al. Short-
648. and long-term treatment of erythrodermic psoriasis with
23. Fiehn C, Andrassy K. Case number 29: hitting three with one ustekinumab: a national and multicenter case series. J Am
strike: rapid improvement of psoriatic arthritis, psoriatic Acad Dermatol. 2014;70(5):AB189.
erythroderma, and secondary renal amyloidosis by treatment 42. Talat H, Wahid Z, Feroz F, Sajid M. Erythrodermic psoriasis and
with infliximab (Remicade). Ann Rheum Dis. 2004;63(3):232. hepatitis C infection treated with pegylated interferon and

Downloaded for ABDUL HAMEED ([email protected]) at ClinicalKey Global Guest Users from ClinicalKey.com by Elsevier on June 25, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
158 Carrasquillo et al J AM ACAD DERMATOL
JULY 2020

anti-TNFa a(etanercept) therapy. J Coll Physicians Surg Pak. with secukinumab for psoriasis. JAAD Case Rep. 2018;4(5):
2017;27(9):S77-S79. 486-488.
43. Romero-Mat
e A, Garc
ıa-Donoso C, Martinez-Mor
an C, Hern
an- 51. Mumoli N, Vitale J, Gambaccini L, Sabatini S, Brondi B, Cei M.
dez-N
un~ez A, Borbujo J. Long-term management of Erythrodermic psoriasis. QJM. 2014;107(4):315.
erythrodermic psoriasis with anti-TNF agents. Dermatol Online 52. Richetta AG, Maiani E, Carlomagno V, et al. Treatment of
J. 2010;16(6):15. erythrodermic psoriasis in HCV1 patient with adalimumab.
44. Esposito M, Mazzotta A, de Felice C, Papoutsaki M, Chimenti S. Dermatol Ther. 2009;22(Suppl 1):S16-S18.
Treatment of erythrodermic psoriasis with etanercept. Br J 53. Vidal D, Peramiquel L, Olivella R, Villar M, Petiti G, Gonz
alez A.
Dermatol. 2006;155(1):156-159. Erythrodermic psoriasis successfully treated with adalimumab:
45. Piqu
e-Duran E, P
erez-Cejudo JA. Psoriatic erythroderma a case study. J Eur Acad Dermatol Venereol. 2013;27(S4):68.
treated with etanercept [in Spanish]. Actas Dermosifiliogr. 54. Saeki H, Nakagawa H, Nakajo K, et al. Efficacy and safety of
2007;98(7):508-510. ixekizumab treatment for Japanese patients with moderate to
46. Weng HJ, Wang TS, Tsai TF. Clinical experience of severe plaque psoriasis, erythrodermic psoriasis and general-
secukinumab in the treatment of erythrodermic psoriasis: a ized pustular psoriasis: results from a 52-week, open-label,
case series. Br J Dermatol. 2018;178(6):1439-1440. phase 3 study (UNCOVER-J). J Dermatol. 2017;44(4):355-362.
47. Mugheddu C, Atzori L, Lappi A, Pau M, Murgia S, Rongioletti F. 55. Lee WK, Kim GW, Cho HH, et al. Erythrodermic psoriasis treated
Successful secukinumab treatment of generalized pustular with golimumab: a case report. Ann Dermatol. 2015;27(4):446-449.
psoriasis and erythrodermic psoriasis. J Eur Acad Dermatol 56. Sano S, Kubo H, Morishima H, Goto R, Zheng R, Nakagawa H.
Venereol. 2017;31(9):e420-e421. Guselkumab, a human interleukin-23 monoclonal antibody in
48. Mateu-Puchades A, Santos-Alarco
n S, Martorell-Calatayud A, Japanese patients with generalized pustular psoriasis and
Pujol-Marco C, S
anchez-Carazo JL. Erythrodermic psoriasis and erythrodermic psoriasis: efficacy and safety analyses of a 52-
secukinumab: our clinical experience. Dermatol Ther. 2018; week, phase 3, multicenter, open-label study. J Dermatol.
31(4):e12607. 2018;45(5):529-539.
49. Galluzzo M, D’Adamio S, Campione E, Mazzilli S, Bianchi L, 57. Viguier M, Pages C, Aubin F, et al. Efficacy and safety of
Talamonti M. A clinical case of severe disease burden: an biologics in erythrodermic psoriasis: a multicentre, retrospec-
erythrodermic psoriatic patient treated with secukinumab. J tive study. Br J Dermatol. 2012;167(2):417-423.
Dermatolog Treat. 2018:1-11. 58. Sahel H, Otsmane F, Bouadjar B. Treatment of erythrodermic
50. Rongioletti F, Mugheddu C, Murgia S. Repigmentation and psoriasis with biological therapies in two cases. J Eur Acad
new growth of hairs after antieinterleukin-17 therapy Dermatol Venereol. 2016;30(S6):102.

Downloaded for ABDUL HAMEED ([email protected]) at ClinicalKey Global Guest Users from ClinicalKey.com by Elsevier on June 25, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.