Psoriasis is a chronic, inflammatory, remitting/relapsing autoimmune condition involving a dysregulated inflammatory response of the interleukin (IL) 23/T-helper (Th)-17 pathway. Greater understanding of the immune-mediated pathology of the disease has led to the development of numerous biological therapies and biosimilars that target the various inflammatory pathways. Each biologic has a unique mechanism of action, pharmacodynamics, and pharmacokinetics resulting in different clinical efficacy and tolerability. This case describes a 64-year-old female with a nine-year history of plaque psoriasis, predominantly affecting her feet, who was successfully treated with brodalumab having previously failed multiple topical and systemic therapies including six other biologicals. To date, there are few guidelines to help physicians select the optimal biology agent and none that have looked specifically at plantar psoriasis. For this patient, finding a biologic that worked and was tolerable was a process of trial and error that took four years. The results achieved in this previously refractory patient with difficult-to-treat psoriasis may be due to the unique mechanism of action of brodalumab, though this will need to be confirmed in larger studies.
Psoriasis is a T-cell meditated disease involving a dysregulated IL-23/Th-17 inflammatory response. With greater understanding of the pathogenesis of the disease, biologic agents that target specific cytokines have been developed. To date, 10 monoclonal antibody drugs and 6 biosimilars that target 3 main pathways: tumor necrosis factor α, IL-23, and IL-17 have been approved for the treatment of plaque psoriasis.1 While most of these biologics demonstrate similar efficacy in clinical trials, patient response in real-world settings is unpredictable and highly variable.2
Psoriasis involving the hands and feet affects only about 30% of patients with plaque psoriasis but is a uniquely problematic form of the disease.3 Although the total body surface area (BSA) may be small, the impact of hand or foot psoriasis on a patients' quality of life can be significant. The location of the lesions often prevents patients from participating in activities of daily living. Patients with hand and foot involvement are affected to a greater degree by physical aspects of the disease, such as pain, discomfort, cracking, and bleeding of the skin.4 Furthermore, as this case demonstrates, hand and foot psoriasis is difficult to treat and often refractory to multiple therapies. The toll that hand and foot involvement can take on a patient physically, psychosocially, and even economically requires that the bar for treatment success be raised when treating this specific subpopulation.
A 64-year-old Caucasian female was first seen in our office in October 2014 for evaluation of bilateral plantar psoriasis. Other than psoriasis for the past five years, she had no past medical or surgical history, no known allergies, and was a former smoker. Prior psoriasis treatments included calcipotriene cream, flucinonide cream, calcipotriene and betamethasone dipropionate (Taclonex®, Leo Pharma) topical suspension 0.005%/ 0.064%, Tazarotene (Tazorac®) cream, clobetasol propionate cream and lotion, methotrexate 20 mg once a week for a total life time dose of 1120 mg, adalimumab (Humira®, Abbvie) 40 mg subcutaneous every other week, and flurandrenolide tape.
At her initial consult, inspection of both feet revealed erythematous plaques with thick adherent silvery scale (Figure 1).
Inspection of skin outside of affected area showed no abnormalities. The patient was being treated with subcutaneous ustekinumab (Stelara®, Janssen) injections every 12 weeks and advised to perform twice weekly bleach water soaks to decrease
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