Rapid and Sustained Improvement in a Patient With Plaque Psoriasis Switched to Brodalumab After Failing Treatment Clearance on Six Other Biologic Therapies

January 2020 | Volume 19 | Issue 1 | Case Reports | 86 | Copyright © January 2020


Published online December 19, 2019

Kathleen Haycraft DNP, Linda Cooke MD

Dermatology, Hannibal, MO

guselinfection risk. Over time, the duration of efficacy of ustekinumab waned and the patient began to experience flare ups in her feet between injections and the development of new psoriasis plaques on her hands and elbows, despite doubling the dose, and decreasing the injection interval to 10 weeks. In July 2015, apremilast (Otezla®, Celgene) 30 mg twice daily was added to her treatment regimen. At 3-month follow-up, although there was improvement in her feet and right palm, she had developed new erythematous plaque with thick adherent silvery scale on her right and left elbows and right and left legs. Despite ongoing treatment with ustekinumab and apreminlast, she continued to have intermittent flares and was advised to apply calcipotriene and betamethasone dipropionate (Enstilar®, Leo Pharma) foam, 0.005%/0.064% twice daily when flared.

In March 2016, she developed culture proven methicillin-resistant staphylococcus aureus (MRSA) on both feet which was treated with doxycycline.

In May 2016, she was switched from ustekinumab to secukinumab (Cosentyx®, Novartis) 300 mg subcutaneous injections weekly for 5 weeks and then every 4 weeks and advised to use UVB at least twice weekly. Apremilast was discontinued as patient did not feel it was helping. At this time, she was also diagnosed with psoriasiform dermatitis on the right lower leg and was complaining of flaring, tingling in her feet and pain when walking.

In June 2016, she developed another persistent MRSA infection in her feet, which was treated with multiple 30-day courses of doxycycline. In July, she was switched from secukinumab to ixekizumab (Taltz®, Lilly) due to constant flaring and increased foot itch and pain. She returned for follow-up after three ixekizumab injections, complaining of worsening symptoms and foot pain. Inspection of left lower leg, right lower leg, right plantar foot, and left plantar foot showed deep, seated vesicles with overlying erythematic, fissures, scaling, and honey crusting.

In June 2017, apremilast was added to ixekizumab due to continued worsening symptoms and the patient was advised to use betamethasone cream and flurandrenolide tape daily. At twomonth follow-up, the patient stated that she had seen minimal improvement since adding apremilast and that she did not like ixekizumab injections because they caused "stabbing pain, redness, and a baseball-size knot at the injection site."

Both biologics were discontinued, and she was started on guselkumab (Tremfya®, Janssen). At 1 and 3-month follow-up of the first injection, the patient stated that her symptoms were no better and that her feet hurt continuously, and that she would flare five days before injections became due.

In February 2018, she presented in our office with severe foot pain and a recurrence of culture proven MRSA, which was treated with bleach baths and doxycycline and we initiated the
process to switch her from guselkumab to brodalumab (Siliq®, Ortho Dermatologics). Brodalumab injections were started in March 2018 and she was seen for follow-up in August at which time her plantar psoriasis showed significant improvement. The patient indicated that her psoriasis was the best it had been in years, despite increased emotional stress due to the sudden death of her husband. On examination both feet showed improving, erythematous plaque with thick adherent silvery scale with decreased cracking of the plantar foot. Inspection of skin outside of affected area revealed no abnormalities (Figure 2).

At the time of writing, the patient has been on brodalumab 210 mg subcutaneous injections every other week for 15 months and her condition continues to improve. We will follow her every three months.

DISCUSSION

Difficult-to-treat areas of plaque psoriasis, such as the palms and feet, may not respond well to traditional treatment algorithms and may be associated with disproportionately high physical and psychosocial burdens.5-7 Additionally, the management of patients with recalcitrant disease is a challenge for even the most experienced dermatologists. While the availability of biologic medications for psoriasis has reduced the challenge considerably, as this case shows, they have not eliminated it.

And although emerging evidence from head-to-head randomized clinical trials provides pertinent information regarding the safety and efficacy of biologic agents in the treatment of moderate-to-severe psoriasis, and clues as to which agents may work best for patients with certain disease related factors and comorbid conditions, this case underscores the importance of providing personalized therapy for each patient based on individual clinical outcomes and tolerance of specific treatments.

To date, there are few guidelines to help physicians select the optimal biology agent for their patient and none that have looked specifically at plantar psoriasis. For this patient, finding a biologic that proved to have both efficacy and safety was a process of trial and error that took four years. Prior to starting treatment with brodalumab, the patient had previously tried and failed treatment clearance with adalimumab, apremilast, guselinfection