Experts in dermatology hypothesize about the management of patients with chronic vs acute GPP episodes.
Erin Boh, MD: I will say it is a very easy drug to use and you don’t use it all the time. You might have patients who are on it more. When I say regularly, not like you would do it regularly. How do you approach a patient who may have a chronic generalized pustulosis in an outpatient setting and not in this acute emergency situation where they’re hospitalized and you have all these other comorbidities and issues to deal with?
Mark Lebwohl, MD: Yes. The way I’m treating that is going to change as soon as we have spesolimab available. That information has been presented publicly at the 2023 World Congress of Dermatology, where subcutaneous monthly spesolimab was highly effective at preventing outbreaks of the disease. But we don’t have that yet, so for now, I keep them on maintenance therapy, like your patient. In Japan, several of the drugs we use are approved for pustular psoriasis. I don’t like to use cyclosporine long term, so I don’t have any patients on those.
I do use a lot of oral retinoids. So, when it is tolerated, I have patients on low-dose oral acitretin. Several of the interleukin-17 blockers, TNF [tumor necrosis factor] blockers, and interleukin-23 blockers are approved in Japan. The criteria for approval for some of those drugs was any improvement at all. In other words, you didn’t have to be clear or almost clear to get approval. If you went from 51% to 50% body surface area, that was deemed a treatment success. That really speaks to how difficult it is to treat pustular psoriasis with the old drugs we have.
But until we had spesolimab, what I would use was often IL [interleukin]-17 blockers, and often in conjunction with acitretin. In fact, if a patient came to the emergency department, that’s what my residents would start the patients on, an IL-17 blocker and oral acitretin. Having said that, when the new spesolimab comes out, I will likely switch those patients over.
Erin Boh, MD: Will you put them on any other maintenance therapy? My patient never had a chronic course of it, so we did the 2 treatments at 90 mg each. She was getting better, we weaned her off steroids completely, and I opted to put her on an IL-23 because I think the IL-17 worked quicker. But at the time she got her pustular psoriasis, she already had her loading doses of the IL-17 and really marched through that, so I opted to put her on IL-23. I did the IL-23 because she had a very good response to the IL-12/IL-23 to ustekinumab 4 years before. In the literature, I found data showing that when you do ustekinumab first and then transfer them over to the IL-23, they get a very sharp, brisk response. And that’s what we did. She’s been on the IL-23 since, with no more outbreaks. She’s doing quite well.
I did that because her arthritis was so bad. I didn’t want to go back to an IL-17 because, although it’s very good for arthritis, I wasn’t sure I really felt the steroids were the trigger. But she had these other confounders, so I didn’t want to give her IL-17 when that could have been the trigger. But I think both worked very well and pretty quickly to get them under control.
Mark Lebwohl, MD: Yes. So again, if somebody has chronic disease, that’s treated one way. If somebody has an acute onset of disease, we go for the faster drugs. We don’t have safety data on the use of spesolimab with other biologics. As a rule, acitretin is not immunosuppressives, so it’s pretty easy to use that with almost anything. But as monotherapy, it’s not greatly effective. Although for pustular psoriasis, it’s probably more effective than it is for plaque psoriasis, so that is a reasonable choice. Using the other biologics with spesolimab is something I’m pretty sure we are going to get experience doing, because spesolimab is great for pustular psoriasis, but when someone has a background of bad plaque psoriasis, it may not be good enough. You’re going to need another drug for the plaque psoriasis. I don’t think the combination is contraindicated. Getting insurance to pay for it is a whole other story. That will be a challenge.
Erin Boh, MD: Something to caution prescribers about—or just in general as you treat patients with psoriasis—I like to tell all of them a couple things when I first meet them. One is that psoriasis forever. The second thing is to not let other doctors give them steroids. I tell them to tell their doctors that they have psoriasis, because that’s how many patients get into the boat they’re in. In my patient’s case, she was a nurse manager, and she knows the issues with steroids, but she let her primary care doctor give her Kenalog shots—being an insulin-dependent diabetic—followed by a taper of 40 mg a day of prednisone. So, I tell my patients that all these are things they don’t ever want to do unless they check with me. We really need to spend a bit more time educating patients on the do’s and don’ts of psoriasis.
Mark Lebwohl, MD: Yes, I agree.
Erin Boh, MD: That might help a little bit.
Mark Lebwohl, MD: Yes, it does also help to tell the patient to be wary of steroids, and to have them call you if anyone ever wants to.
Transcript Edited for Clarity