Psoriasis & SCC: Adalimumab, acitretin control PUVA-related side effects

The dramatic improvement of a psoriasis patient who had developed squamous cell carcinoma secondary to PUVA treatment illustrates that adalimumab and acitretin work synergistically, a physician familiar with the case says.

Key Points

Miami - Combining adalimumab with acitretin has halted squamous cell carcinoma (SCC) development in a patient with psoriasis who developed skin cancers after long-term psoralen and ultraviolet light (PUVA) treatment, one of his physicians says.

"This is a patient with long-standing recalcitrant psoriasis. When he presented to our office, we had to treat his psoriasis, as well as the secondary effects of treatment regimens that he'd received in the past," says Eliana Krulig, M.D., then a research fellow at Florida Academic Dermatology Centers (FADC), Miami.

Such problems continue to occur because before biologic drugs became available, many of dermatologists' previous options for treating psoriasis (such as PUVA, methotrexate and cyclosporine) were quite toxic, she says.

Case study

"After more than 20 years of PUVA therapy," Dr. Krulig says, "the patient had severe psoriasis associated with multiple SCCs that started over the course of about a year."

The patient's history also includes one year of methotrexate use and several mid- to high-potency topical steroids. The patient's psoriasis had varied in extent and severity over the years, though it had largely been plaque-type with an intermittent erythrodermic component, Dr. Krulig says.

When the patient was referred to FADC, he was already on adalimumab (Humira, Abbott), 40 mg subcutaneous injections every other week, after trying several other biologic drugs. Efalizumab had achieved some success, but the patient had to discontinue this drug due to a medication-related rebound.

Furthermore, the patient had been diagnosed with nine SCCs between 2004 and mid-2005. At his first FADC appointment, Dr. Kerdel diagnosed five additional SCCs, which were widely distributed, mainly on the patient's upper and lower extremities, Dr. Krulig says.

All the SCCs were progressively removed by Mohs surgery, and the patient was started on acitretin (25 mg daily).

Soon after, the patient experienced substantial improvement in his psoriasis and a decrease in the incidence of SCC, Dr. Krulig says.

"There are many reports addressing the use of acitretin for preventing SCC in high-risk groups, such as patients who had received previous PUVA therapy, and in post-transplant patients receiving immunosuppressive drugs," she says. However, Dr. Krulig says that until recently, "Very few reports addressed the concurrent use of acitretin and a biologic drug for a patient like this."

Lesson learned

The main lesson from the case is that not only do adalimumab and acitretin work independently, but their effects also increase synergistically when taken together, Dr. Krulig says.

Since the patient began combination therapy, he's experienced no new SCCs.

"His liver enzymes and lipids are within normal limits, and he's satisfied with the treatment," Dr. Krulig says.

The patient experienced a small psoriasis flare in mid-2008, Dr. Krulig says. But on the whole, she says, "His progress has been amazing."

Disclosure: Abbott Laboratories funded the writing and preparation of a poster based on this study, but Dr. Krulig reports no financial interest in the company.

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