Challenging Psoriasis Cases 2012

Bruce Strober, MD, PhD

 

Case Study 1 – IL-12/23 Inhibitors
  • 54 year-old man
  • Severe psoriasis affecting 25% BSA, PGA = 3
  • No psoriatic arthritis
  • Failure to respond to:
    • Methotrexate 20 mg weekly for 12 weeks
    • Etanercept (primary failure)
    • Adalimumab (primary failure)
    • Infliximab (initial response, with subsequent failure)
    • History of:
      • Hypertension
      • Hypercholesterolemia
      • Hypertriglyceridemia
      • Obese, 120 kg, BMI = 33

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There is concern for this patient because he is at a relatively high risk for cardiovascular disease. However, he has not responded to various treatments and needs therapy in order to function.

      • How do you discuss ustekinumab with this patient prior to initiation of therapy?

Discuss his risks of cardiovascular disease and conduct a benefit/risk assessment of ustekinumab prior to starting therapy

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Case Study 2- Topical Therapy
      • 42 year-old man
      • Psoriasis affecting 4% of BSA
        • Inverse pattern
          • Inguinal
          • Intergluteal and perianal
      • Refractory to alclometasone dipropionate cream
      • No psoriatic arthritis

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Case Study 3- Scalp Psoriasis
      • 22 year-old woman
      • Severe scalp psoriasis, affects 50% of scalp surface area, failed:
        • OTC preparations (T-gel)
        • Fluocinolone acetonide topical scalp oil 0.01%
        • Clobetasol shampoo, solution and foam

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Case Study 4- Refractory Local Psoriasis in a Patient on Biologic Therapy
      • 46 year-old man with > 20 years of severe psoriasis and psoriatic arthritis
      • Baseline: 20% BSA, PGA = 4
      • Currently managed effectively with:
        • TNF-inhibitor in combination with MTX 10 mg per week
        • BSA currently 4%, with residual disease on the elbows and lower extremities
        • Refractory to topical class 1 corticosteroids

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Case Study 5- Latent TB
      • 52 year-old man with 40% BSA
      • Active psoriatic arthritis
      • Only treated with UV Phototherapy and topicals, neither of which is effective
      • PPD is positive to 12 mm induration
      • Chest X-ray shows no infiltrate and chest CT is normal

What if this patient had previous BCG vaccination?

      • Verify latent TB status with Quantiferon Gold test

What are your steps to starting therapy for this patient?

      • Quantiferon Gold test
      • If positive, treat with a full course of latent TB infection prophylaxis prior to initiation of immunosuppressive/immunomodulatory therapy. Therapy for psoriasis may be begun 1 month into treatment for latent TB.
      • Discuss various treatment options review the benefits/risks

 

How do you follow/monitor a patient with treated latent TB while on a TNF-inhibitor?

      • Be vigilant of signs and symptoms of TB

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Case Study 6- New Onset Psoriasis
      • 53 year-old woman
      • Crohn’s disease on TNF-inhibiting antibody with gastrointestinal disease is well-controlled
      • Develops palmoplantar pustular dermatitis

Could the psoriasis have been induced by the TNF-inhibitor?

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