INTRODUCTION
Psoriasis is a common, chronic, immune-mediated systemic disease with a relapsing and remitting course. Arthritis occurring in patients with psoriasis is termed as “psoriatic arthritis”, which is a chronic inflammatory form of arthritis with a highly variable clinical presentation and is frequently associated with skin and nail psoriasis.1-4 Biologic agents target specific steps in the immune cascade and interrupt the immune process contributing to psoriasis, unlike generalized immunosuppressive action of drugs such as methotrexate (MTX), cyclosporine, etc. They are manufactured proteins, generally well tolerated, and limited data have demonstrated them to be safe in moderate to severe plaque psoriasis for long-term use. However, they have been associated with a small increase in the risk for infection due to their immunosuppressive action.5,6
Case Presentation
A 46-year-old woman presented with a 12-year history of severe plaque psoriasis and psoriatic arthritis. She failed to respond to several prior treatments including topical corticosteroids, cyclosporine and NBUVB phototherapy. The PASI score was 42, so she was started with subcutaneous (SC) injections of adalimumab, 80 mg at week 0 and 1, and later 40 mg every 2 weeks, combined with subcutaneous 25 mg methotrexate administered weekly. Significant clearance of psoriatic plaques and the diminution of arthritis ensued after three months. The PASI score had reduced to 8. However, a few months later, she developed increased gastrointestinal intolerability and extreme fatigue. The patient was advised to discontinue use of methotrexate and adalimumab. Thereafter, guselkumab 100 mg SC was prescribed at week 0 and 4, and then every 8 weeks. But, the patient also continued to use adalimumab without informing the physician, considering increased effectiveness of the combined therapy. Two months later, she displayed almost completely clear skin and had no symptoms of psoriatic arthritis as well. The PASI score was 2 after the combination therapy.
