Updates on the Treatment of Erythrodermic Psoriasis

Figures & data

Table 1 Studies of Conventional Oral Immunosuppressive Agents in EP Patients

Treatment	Author (Year)	Number of Subjects	Study Design	Results	Adverse Events
MTX	Collins et al^Citation18 1991	7	R	4 (57.1%) Patients with excellent response, 2 (28.6%) patients with good response, 1 patient failed.	NR
MTX	Kumar et al^Citation21 (1994)	5	R	2 (40%) Patients achieved disease-free interval for 14 weeks. All patients relapse within 14 weeks.	Nausea, vomiting
CsA	Giannotti et al^Citation26 (1993)	33	Case series	22 (67%) Patients achieved complete remission in a median time of 2–4 months after 6 months of treatment.	Hypertension, cerebrovascular disorder
CsA	Bruzzese et al^Citation27 (2009)	1	Case report	Under CsA 3 mg/kg, complete remission was seen within 3 months.	NR
CsA + etretinate	Kokelj et al^Citation33 (1998)	3	Case series	After treatment for 11–18 days, remission was seen.	Xerosis, chelitis, GI upset
CsA + UVB	Franchi et al^Citation35 (2004)	7	Case series	After 9 weeks, PASI score Reduction by 57.6, compared with placebo. points	None
Acitretin CsA	Charbit et al^Citation36 (2016)	2 2	R	After 3 months of treatment, 2 patients treated with acitretin failed to achieve greater than 50% clearance. 1 patient treated with CsA had “good” response (>75%).	NR
Etretinate	Kim et al^Citation39 (1991)	12	Case series	Averaged 19.9 days for complete disappearance of scales. After 2–11 months of treatment, 10 (83.3%) patients had satisfactory results.	Cheilitis, elevated lipid profiles level
Etretinate	Rosińska et al^Citation40 (1988)	5	Case series	2 (40%) Patients with clinical improvement.	Focal osteoporosis
MMF	Geilen et al^Citation47 (1998)	2	Case series	After treatment for 6 weeks, both patients reported with 70% skin improvement.	None

Abbreviations: CsA, cyclosporine; EP, erythrodermic psoriasis; GI, gastrointestinal; MTX, methotrexate; MMF, mycophenolate mofetil; NR, not reported; PASI, Psoriasis Area and Severity Index; R, retrospective; UVB, ultraviolet B.

Table 2 Studies of Tumor Necrosis Factor Antagonist in EP Patients

Biologic Agent	Characteristics
Etanercept	Fully humanized, soluble, recombinant fusion protein
Infliximab	Mouse–human chimeric monoclonal antibody, IgG1
Adalimumab	Fully humanized, monoclonal antibody, IgG1
Golimumab	Fully humanized, monoclonal antibody, IgG1κ
Treatment	Author (Year0	Number of Subjects	Study design	Results	Adverse Events
Infliximab + acitretin	Takahashi et al^Citation43 (2007)	7	Case series	After third infusion of infliximab, all patients reported 90% improvement.	None
Etanercept	Esposito et al^Citation48 (2006)	10	Case series	At week 12, 5/10 (50%) patients achieved PASI 75. At week 24, 6/10 (60%) patients achieved or maintained PASI 75, 2/10 patients (20%) maintained improvement between PASI 50 and PASI 75.	UTI pruritus
Etanercept	Piqué-Duran et al^Citation49 (2007)	1	Case report	Achieved PASI 100 at week 9	NR
Infliximab Etanercept	Romero-Maté et al^Citation50 (2010)	1	Case report	At week 20, achieved PASI 100 with infliximab. Maintained etanercept therapy for 34 months	NR
Infliximab (n=24) Adalimumab (n=7) Etanercept (n=6) Ustekinumab (n=3) Efalizumab (n=2)	Viguier et al^Citation51 (2011)	28	R	At week 12–14, 48% achieved PASI 75 with infliximab, 50% with adalimumab, 40% with etanercept.	Bacterial infection in 7/12 serious adverse event. Adalimumab: lymphoma. Ustekinumab: sudden death. Infliximab: immunoallergic reaction, suicide attempt.
Etanercept Infliximab	Sahel et al^Citation52 2016	2	Case report	At week 12, one case with etanercept from PASI 32.8 to 7. The other one improved to PASI 4.8 with infliximab	NR
Etanercept + MTX	Fraga et al^Citation53 (2011)	1	Case report	After 3 months of treatment, erythroderma resolved.	None
Infliximab	Poulalhon et al^Citation54 (2006)	5	Case series	After 14 weeks, 2 (40%) patients achieved PASI 90, and 3 patients achieved PASI 75.	Arthralgia, delayed infusion reaction, pneumonia.
Infliximab + MTX	Lisby et al^Citation55 (2004)	3	Case series	All patients with total clearance after first dose of infliximab.	None
Infliximab + MTX	Heikkila et al^Citation56 (2005)	4	Case series	All patients reported rapidly improvement after 2 or 3 infusions of infliximab.	None
Infliximab	Torii et al^Citation59 (2011)	8	UCT	At week 50, 4 (50%) with reduction of >5 in DLQI.	Nasopharyngitis
Golimumab	Lee et al^Citation70 (2015)	1	Case report	82% Reduction in PASI score after the third injection.	None

Abbreviations: CsA, cyclosporine; DLQI, Dermatology Life Quality Index; EP, erythrodermic psoriasis; MTX, methotrexate; NR, not reported; PASI, Psoriasis Area and Severity Index; R, retrospective; TNF, tumor necrosis factor; UCT, uncontrolled clinical trial; UTI, urinary tract infection.

Table 3 Studies of IL‑12/23, IL-23 Antagonist in EP Patients

Biologic Agent	Targets	Characteristics
Ustekinumab	p40 Subunit of IL-12 and −23	Fully humanized, monoclonal antibody, IgG1κ
Guselkumab	p40 Subunit of IL −23	Fully humanized, monoclonal antibody, IgG1
Risankizumab	p40 Subunit of IL −23	Fully humanized, monoclonal antibody, IgG1
Treatment	Author (Year)	Number of Subjects	Study Design	Results	Adverse Events
Ustekinumab	Pescitelli et al^Citation74 (2015)	22	R	At week 16, 70% of patients achieved PASI 75. More than 80% at week 28.	None
Ustekinumab	Santos-Juanes et al^Citation75 (2010)	2	Case series	At week 4, PASI score improvement: 81% and 94%, respectively. At week 12, PASI score improvement: 94% and 97%, respectively.	NR
Ustekinumab	Wang et al^Citation76 (2011)	8	Case series	At week 12 and 28, 50% of patients achieved PASI75. 12.5% achieved PASI 90 at 12 weeks, and 37.5% achieved PASI 90 at 28 weeks.	NR
Ustekinumab	Saraceno et al^Citation80 (2013)	2	Case series	Both of patients achieved PASI at week 12. One case maintained PASI 75 for 12 months. One case maintained PASI 90 for 64 weeks.	NR
Guselkumab	Sano et al^Citation86 (2018)	11	Case series	At week 16, 10 (90.9%) with treatment success.	4 (36.4%) Patients with nasopharyngitis.
Guselkumab	Megna et al^Citation87 (2020)	1	Case report	After 20 weeks of treatment, patient achieved PASI 100, and maintaining to week 48.	NR
Guselkumab	Chiang et al^Citation88 (2021)	13	Case series	PASI 75 rate: At weeks 4, 12, 20, and 28 was 15.4%, 38.5%, 53.9%, and 46.2%.	None
Risankizumab	Suleiman et al^Citation89 (2020)	4	Phase 3 open-label clinical trial	At week 16, all patients achieved PASI 90.	NR

Abbreviations: EP, erythrodermic psoriasis; IL, interleukin; NR, not reported; PASI, Psoriasis Area and Severity Index.

Table 4 Studies of IL‑17 Antagonist in EP Patients

Biologic Agent	Targets	Characteristics
Secukinumab	Anti-IL-17A	Fully humanized, monoclonal antibody, IgG1κ
Ixekizumab	Anti-IL-17A	Humanized, monoclonal antibody, IgG4
Brodalumab	Anti-IL-17R	Fully humanized, monoclonal antibody, IgG2
Treatment	Author (Year)	Number of Subjects	Study Design	Results	Adverse Events
Secukinumab	Weng et al^Citation90 (2018)	10	Case series	At week 16, 4 (40%) achieved PASI 90, (70%) of patients achieved PASI 75. At week 24, 30% achieved PASI 90 and 60% achieved PASI 75.	None
Secukinumab	Mugheddu et al^Citation91 (2017)	2	Case series	2 (100%) Patients achieved PASI 75 at week 4. Maintained efficacy were seen at 12–24 week follow-up.	None
Secukinumab	Mateu-Puchades et al^Citation92 (2018)	5	Case series	3 (60%) Patients achieved PASI 75 at week 4. All patients achieved PASI 90 at week 16 and 80% had PASI 100.	NR
Secukinumab	Galluzzo et al^Citation93 (2018)	1	Case report	At week 12, the patients achieved PASI 75.	None
Secukinumab	Rongioletti et al^Citation94 (2018)	1	Case report	At week 12, the patients achieved PASI 100.	None
Secukinumab	Pizzatti et al^Citation99 (2020)	1	Case report	7 days after injection, PASI score improved from 31.5 to 17.6.	None
Ixekizumab	Saeki et al^Citation101 (2017)	8	Case series	At week 52, 8 (100%) patients achieved PASI75, 6 (75%) achieved PASI90, and 1 patient achieved PASI 100.	Allergic reaction, infection, injection site reaction, hepatic disorder
Ixekizumab	Megna et al^Citation103 (2019)	1	Case report	After 6 weeks, patient achieved PASI 100, and maintaining to week 24.	None
Ixekizumab + acitretin, Secukinumab	Pangilinan et al^Citation105 (2020)	1 1	Case series	After two weeks of ixekizumab injection, PASI score improved from 36 to 5. The other one achieved PASI 100 after 4 doses of secukinumab.	None
Ixekizumab	Lo et al^Citation106 (2019)	9	Case series	4 (44%) Patients achieved PASI 75 at week 12.	4 (44.4%) Patients with injection site reaction.
Ixekizumab	Lo et al^Citation107 (2021)	14	Case series	After 52 weeks, three (21.4%) patients achieved PASI 75.	5 (35.7%) Patients with injection site reaction. 1 patient with vulvovaginal candidiasis.
Brodalumab	Yamasaki et al^Citation108 (2017)	18	Case series	After week 12, 14 (77.8%) patients achieved PASI 75, 9 (50%) patients achieved PASI 90, and 3 (16.7%) patients achieved PASI 100. At week 52, 88.9%, 88.9%, and 61.1% achieved PASI 75, PASI 90, and PASI 100.	Nasopharyngitis
Brodalumab	Bernardini et al^Citation109 (2020)	1	Case report	At week 4, PASI score decreased from 42 to 22.	None
Brodalumab	Megna et al^Citation110 (2020)	2	Case series	One case achieved PASI 90 at week 3. One case achieved PASI 90 at week 12.	None

Abbreviations: EP, erythrodermic psoriasis; IL, interleukin; IL-17R, interleukin-17 receptor; NR, not reported; PASI, Psoriasis Area and Severity Index.

Table 5 Other Treatment in EP Patients

Treatment	Author (Year)	Number of Subjects	Study Design	Results	Adverse Events
Apremilast	Papadavid et al^Citation111 (2017)	1	Case report	Achieved PASI 100 at 20 days. Relapse after week 12.	None
Apremilast	Krishnamoorthy et al^Citation112 (2019)	1	Case report	Achieved PASI 100 at week 10. Remained free of psoriasis for 1 year.	None
Apremilast	Arcilla et al^Citation113 (2016)	1	Case report	NR	Atrial fibrilliation
Apremilast	Mugheddu et al^Citation114 (2020)	1	Case report	NR	None
Naltrexone	Beltran Monasterio et al^Citation115 (2019)	1	Case report	Achieved complete remission after 3 months of treatment.	None
Panitumumab	Nishizawa et al^Citation116 (2012)	1	Case report	Erythrodermic status improved after 10 days of treatment.	None
Coenzyme Q10 + vitamin E +selenium	Kharaeva et al^Citation117 (2009)	7 7 (placebo group)	RCT	After treatment for 30 days, PASI scores for the supplement group were 19 ± 4 compared to 30 ± 5 in the placebo group (p<0.05)	None

Abbreviations: EP, erythrodermic psoriasis; NR, not reported; PASI, Psoriasis Area and Severity Index; RCT, randomized controlled trial.

Figure 1 Treatment algorithm of EP, suggested by the author.

Abbreviations: CsA, cyclosporine; EP, erythrodermic psoriasis; IL, interleukin; TNF, tumor necrosis factor.

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