Biological treatment for erythrodermic psoriasis

ABSTRACT

Introduction

Erythrodermic psoriasis (EP) is an extreme and potentially life-threatening form of psoriasis in which most or all of the body surface area is affected by psoriasis. It occurs in 1–2% of patients with psoriasis and is less responsive to conventional therapies. Biologics have shown promise in the management of EP.

Areas covered

This review briefly discusses the pathophysiology of EP. Current evidence on established and emerging targeted therapies for EP is covered, including anti-TNF-α biologics, IL-12/23, IL-17, and IL-23 inhibitors.

Expert opinion

The need for rapidly acting, safe, and efficacious agents in EP has been met with advent of newer biologics, particularly IL-17 and IL-23 inhibitors. These targeted approaches warrant consideration as first-line management option for the management of EP; however, high-quality evidence regarding their long-term efficacy and safety in EP is lacking. Novel biologics such as bimekizumab and mirikizumab, and nanobodies such as netakimab and sonelokimab have shown promise in the management of plaque psoriasis, and potential of these molecules in management of EP should be explored. Management of patients with prior biologic failure remains a challenge. Guidelines for the management of EP need to be revisited in light of the recent advances.

KEYWORDS:

• Erythroderma
• psoriasis
• erythrodermic psoriasis
• biologic
• TNF-α
• IL-12
• IL-23
• IL-17

Article highlights

• Due to the rarity of erythrodermic psoriasis (EP), high-quality evidence regarding management is lacking.

• Infliximab has been recommended as a first-line therapy for acute EP in view of the rapidity of onset of action.

• Recent literature indicates that anti-IL-17 and anti-IL-23 biologics have rapid onset, high efficacy, and good safety profile in the management of EP.

• There is no evidence supporting use of one biologic over the other, and treatment should be individualized based on disease severity, comorbidities, availability, and pharmacoeconomics.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.