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Treatment Selection in GPP


Boni Elewski, MD, shares her personal experience using generalized pustular psoriasis treatments in the clinical setting.

Raj Chovatiya, MD, PhD: I’ll touch on 1 more point here and just the therapeutic arm because the progression of treatments. I’m kind of curious if that sort of made sense to you or sort of you feel like there was a lot of things tried that you would’ve necessarily gone down that road. Looks like we had methotrexate, tried previously at some point in time, apremilast, an IL-17 blocker that originally did not agree with the individual acitretin as sort of a medication that we think about kind of in that retinoid family as well. Are these all things that you’ve used in the past for patients with pustular-type psoriasis or [do] some of them surprise you a little bit?

Boni Elewski, MD: Yes, I’ve used all of the above for pustular psoriasis. And acitretin is more effective in the palmoplantar version. I haven’t had good luck in the past with GPP [generalized pustular psoriasis], pustular psoriasis. Though one of my first patients I’ve taken care of, and I still have seen him, he was on a high dose acitretin and methotrexate, and this is before we had biologics. And then when we first got, it was infliximab that we added to his treatment, he has been on it and has done very well. And I’m working on getting him spesolimab because he’s been on infliximab, he is not totally clear anymore. It has lost its punch.

Raj Chovatiya, MD, PhD: That’s great. I think that the dangers of something like acitretin, particularly based on the age of the patient, is the fact that you’ve kind of hamstrung them for several years. When it comes to thinking about blood or anything like that, we forget that sometimes it’s another downside that isn’t at the top of mind for a medication that while it can be effective, you have some longer-term things to think about as well. But, obviously, in the case of my patient, she’d also done methotrexate, which didn’t agree with her as well, and she’s had GI [gastrointestinal adverse] effects from most of these medications. So, it was really a dwindling lift. And the reason why I didn’t really spend much time messing around with cyclosporine knowing that I had an option that probably could be more agreed for.

Boni Elewski, MD: My patient that I just referred to couldn’t take cyclosporine because he’s very obese. He has high blood pressure and has some borderline renal issues. So, there are some problems, but I don’t use oral steroids in GPP. I’m kind of afraid of it. Because I’ve seen too many patients develop GPP from the steroid withdrawal.

Raj Chovatiya, MD, PhD: I feel like, from my experience, even in training when I sort of was on the inpatient side a little bit more for the patients that I ever saw with GPP. I felt like that was some antecedent aspect of our history because it’s very easy for our patients in dermatology in the outpatient setting to get oral steroids when somebody doesn’t know what’s going on. And it’s no criticism. Sometimes it’s just really hard to figure out. …[It] can be a quick fix, but this is one of those circumstances when we say that a lot of bad things can happen from steroids. This is, perhaps, one of the worst things you think about in terms of flaring a disease that’s going to be evolving head to toe and get you in the hospital.

Boni Elewski, MD: One of my colleagues won’t use steroids even in patients with psoriasis who have poison ivy, and they’re a mess. They use cyclosporine instead for short course rather than risk them getting GPP with steroids.

Transcript edited for clarity.

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