Successful Treatment of Refractory Plaque-Type Psoriasis and Psoriatic Arthritis With Guselkumab and Adalimumab Combination Therapy: A Case Report

April 2019 | Volume 18 | Issue 4 | Case Reports | 394 | Copyright © April 2019

Dipali Rathod DNB DDVL,a Jeffrey M. Weinberg MD,b Paul S. Yamauchi MD,c Leon H. Kircik MD,d Uwe Wollina MD,e Torello Lotti MD,f Mohamad Goldust MDg

aMumbai, Maharashtra, India bIcahn School of Medicine at Mount Sinai, New York, NY cDermatology Institute and Skin Care Center, Santa Monica, CA; Division of Dermatology, David Geffen School of Medicine at University of California, Los Angeles, CA dIcahn School of Medicine at Mount Sinai, New York, NY eDepartment of Dermatology and Allergology, Städtisches Klinikum Dresden, Academic Teaching Hospital of the Technical University of Dresden, Dresden, Germany fUniversity of Studies Guglielmo Marconi, Rome, Italy gMazandaran University of Medical Sciences, Sari, Iran

Abstract

COPY: A number of biologics have been approved for use in plaque-type psoriasis. They act by either blocking the action of a specific type of cell or protein in the immune system.

CASE PRESENTATION: Herein, we report a case of a 46-year-old woman with a 12-year history of severe plaque psoriasis and psoriatic arthritis who was treated successfully with guselkumab and adalimumab after failure of prior topical corticosteroids, cyclosporine and narrow-band ultraviolet B (NBUVB) phototherapy.

CONCLUSION: There is limited data supporting the combination of biological agents in the management of psoriasis and psoriatic arthritis. This is the first case report of plaque psoriasis with arthritis, successfully treated with guselkumab and adalimumab combination therapy, without concurrent use of other systemic agents during the treatment. However, further studies need to be carried out to evaluate the efficacy and safety of this biologic combination therapy.

J Drugs Dermatol. 2019;18(4):394-396.

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.