New York — Intramuscular (IM) alefacept (Amevive, Biogen) appears to be an effective and well-tolerated treatment for patients with extensive palmoplantar psoriasis, says Wendy Myers, M.D.
Dr. Myers, a medical resident at UMDNJ-Robert Wood Johnson Medical School, New Brunswick, N.J., and Alice B. Gottlieb, M.D., Ph.D., professor of medicine and director, Clinical Research Center, UMDNJ-Robert Wood Johnson Medical School, report their successful experience using IM alefacept 15 mg once a week to treat two patients with recalcitrant, disabling psoriasis of the palms and soles. Both patients achieved substantial clinical improvement that enabled daily function and occurred without any untoward clinical effects or changes in CD4+ T-cell counts.
"To our knowledge, this is the first reported use of alefacept to treat palmoplantar psoriasis. Based on these few cases, we believe that while more conventional therapies might be considered first for this difficult-to-treat and disabling form of psoriasis,alefacept offers a good option to consider when patients are recalcitrant to those interventions," Dr. Myers says.
Case studies One of the patients was a 53-year-old female, who for three years, had suffered with thick, hyperkeratotic, erythematous plaques on the palms and soles of both hands and feet. Areas of localized fissuring were also present.
The palmoplantar psoriasis was interfering with the patient's ability to work and adversely affecting her social functioning as well. Previous therapies that were unsuccessful included topical treatment with corticosteroids, calcipotriene and tazarotene, systemic corticosteroids and PUVA.
Initiation of IM alefacept resulted in significant clearing after five injections. The patient received a total of 12 weekly doses and continued to improve even during a six-week period after treatment was completed.
"Success with topical medications applied to the palms is always challenging because of poor penetration through the relatively thick skin at this site and because greasy vehicles are often not practical. However, for this patient, the deep fissures that made application of topical medications very uncomfortable further compounded those problems. In addition, the PUVA treatments she received were time-consuming and ineffective. Consequently, she was particularly pleased to achieve significant improvement after receiving just five doses of IM alefacept," Dr. Myers says.
The other patient was a 59-year-old female who developed psoriasis during childhood, but did not experience palmoplantar involvement until she was in her 50s. Her ability to work and complete other daily function was also hindered by her palmoplantar disease, and it was also associated with pain on walking. Over a five-year period, she received many therapies including a variety of topical agents, phototherapy, and even methotrexate and cyclosporine.
This patient benefited with substantial improvement allowing better functioning after eight injections of alefacept, while the pain she was experiencing on walking resolved after ten doses.
She completed a 12-week course of alefacept and, while off therapy, had only diffuse erythema with minimal to moderate scaling but no induration. A second course was started after a 10-week interval without treatment, and she benefited with further improvement.
Disclosure: Dr. Gottlieb is an investigator, speaker and consultant for Biogen.