To the Editor: Psoriasis is a chronic inflammatory skin disease affecting 2% of the
population.1 This disease affects the skin and is associated with significant patient
morbidity. Conventional topical and systemic treatment options are numerous with varying
degrees of success and rapidity of action. The immunological pathogenesis of this
condition has substantially grown in the recent years. All the advances have led to
the development of biologic agents that have dramatically altered the treatment of
moderateto-severe psoriasis. Most of these agents are tumor necrosis factor (TNF)
alpha-blockers, such as etanercept, infliximab, and adalimumab, which have shown a
notable efficacy in the treatment of this condition. A new class of biologic agent
ustekinumab, an interleukin (IL)-12 and IL-23 antibody, has shown a significant improvement
when treating psoriasis, without the safety concerns, such as risk of infections associated
to the former biologic agents. We present a case of a patient with severe plaque psoriasis
refractory to multiple therapies, with a good response to ustekinumab.
A 56-year-old male presented to our hospital with recalcitrant plaque psoriasis for
the last 40 years. The previous medical history showed smoking (1 pack per day), hypertension
treated with enalapril 50 mg, and obesity (grade II). A positive family history of
psoriasis was reported: his grandmother and sister had psoriasis. Over the years,
our patient failed to respond to different topical and classic systemic therapies
such as methotrexate and cyclosporine. In 2007, anti-TNF alpha-blockers, infliximab,
and etanercept to standard doses, were also used in standard doses. Although they
gave a significant improvement, the disease relapsed during the following months of
treatment. On examination, severe scaly plaques involving trunk, arms, and legs were
observed (Figure 1). Psoriasis Assessment Score Index (PASI) was 34.2. The clinical
exam did not reveal the signs of concomitant psoriatic arthritis. For the evident
difficulties in management, particularly the lack of long-term efficacy, we considered
to initiate a treatment with ustekinumab. Before starting the new treatment, a complete
laboratory with blood count and chest x-rays were performed. No significant alterations
were found. According to the patient’s weight (108 kg), he was treated using 90 mg
ustekinumab. A dramatic response was observed only 1 week after the first injection,
reaching PASI 75 (Figure 2). On the following-up, the efficacy was maintained and
no local subcutaneous reaction was observed in the injection site.
Psoriasis is a chronic, relapsing immune-mediated inflammatory disease affecting the
quality of life of patients with this condition. The first-line management of this
condition is with topical treatments, including vitamin D analogues, topical steroids,
tar-based preparations, dithranol, and salicylic acid.2 When no satisfactory result
is achieved with these topical agents, systemic treatment may be initiated such as
cyclosporine, methotrexate, and acitretin. Guidelines from the British Association
of Dermatologists suggest that patients with psoriasis may be eligible to receive
interventions with any of the 4 licensed biological agents (infliximab, etarnecept,
adalimumab, and ustekinumab) when they fulfil either of the following specific criteria:
(i) severe clinical disease, defined as PASI ≥10, (ii) intolerance to standard systemic
therapy, (iii) contraindicated, or (iv) lack of response to standard systemic therapy.
3 Despite of all this full range of therapeutic approaches, the treatment of moderate-to-severe
psoriasis can be challenging. As we stated previously, standard systemic therapies
sometimes show initial efficacy in only a certain percentage of patients, whereas
other patients are resistant to any kind of therapy. Our patient suffered from a severe
form of psoriasis that was recalcitrant to other systemic therapies including anti-TNF
alpha-blockers. Although the TNF-alpha has an important role in the pathogenesis of
psoriasis,4 recent studies over the past 5 years have altered the view of psoriasis
as a disease mediated primarily by more specific cytokines, including IL-23 and IL-12.
Ustekinumab is a fully human monoclonal antibody that blocks these specific molecules,
thus inhibiting proliferation of Th1 and Th17 T-cells. Such a unique mechanism of
action leads to the rapid onset of clinical response after the initiation of treatment,
with 60% of patients attaining Physician’s Global Assessment scores of “cleared” or
“minimal” by week 12.5 Treatment with ustekinumab was very well tolerated in our case,
and it resulted in a very rapid and maintained response without any side effect. In
conclusion, ustekinumab provides an effective alternative to current anti-TNF alpha
preparations in psoriasis refractory to other therapies.