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 Table of Contents  
LETTER TO THE EDITOR
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 40-42

Gratifying results of apremilast in unstable erythrodermic psoriasis


Department of Dermatology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India

Date of Submission25-Jun-2021
Date of Decision21-Oct-2021
Date of Acceptance17-Jan-2022
Date of Web Publication11-Jun-2022

Correspondence Address:
Vidya Kharkar
Department of Dermatology, Seth GS Medical College and KEM Hospital, Parel, Mumbai 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdd.ijdd_27_21

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How to cite this article:
Rane MC, Kharkar V. Gratifying results of apremilast in unstable erythrodermic psoriasis. Indian J Drugs Dermatol 2022;8:40-2

How to cite this URL:
Rane MC, Kharkar V. Gratifying results of apremilast in unstable erythrodermic psoriasis. Indian J Drugs Dermatol [serial online] 2022 [cited 2022 Jun 26];8:40-2. Available from: https://www.ijdd.in/text.asp?2022/8/1/40/347287



Sir,

Erythroderma is characterized by diffuse cutaneous erythema, which may be associated with multi-organ dysfunction. Erythrodermic psoriasis is the most common form of erythroderma. We describe a case of psoriatic erythroderma, which was successfully treated with a combination of apremilast and cyclosporine. Apremilast, a relatively safe drug, has no major side effects. A 33-year-old male came with chief complaints of redness and peeling of skin and itching all over the body since 3 years. Three years back, the patient developed severely itchy red lesions all over the body, which were associated with scaling. Biopsy of the lesion was suggestive of chronic plaque psoriasis progressing to erythroderma, and the patient was started on capsule cyclosporine 100 mg thrice daily with methotrexate 7.5 mg/week and was maintained on it for 4 months in a gradually tapering dose. One year later, he developed similar lesions and was started on capsule cyclosporine 100 mg thrice daily and acitretin 35 mg along with systemic steroids. Owing to the stopping of systemic steroids, there was an exacerbation of lesions. On cutaneous examination, the patient had a body surface involvement of more than 90% with diffuse erythema with multiple plaques with adherent scales present over the plaques over the trunk and extremities surmounted by multiple pustules [Figure 1]. Psoriasis Area and Severity Index (PASI) score was 39.8. A provisional diagnosis of unstable erythrodermic psoriasis with localized pustular psoriasis was made. On histopathology, elongation of rete ridges, suprapapillary thinning, dilated capillaries and parakeratosis, and spongiform pustules of Kogoj were seen, suggestive of psoriasis [Figure 2]. Biopsy from the pustule showed neutrophilic infiltration. Unstable erythrodermic psoriasis not responding to treatment with localised pustular psoriasis. Since the patient was already treated with multiple drugs, which failed to control the condition, we started the patient on the tablet apremilast along with cyclosporine 100 mg twice a day. The dose of apremilast was increased by 10 mg every week starting from 10 mg once a day. With this regimen, the patient did not experience any side effects. The dose was increased to 30 mg twice a day. The patient cleared dramatically over a period of 1 month. Cyclosporine was continued and tapered and maintained on 100 mg twice a week. The patient remains in the state of remission. PASI score after 1 month was 18 [Figure 3] and after 3 months was 4.2 [Figure 4].
Figure 1: More than 90% body involvement present. Diffuse erythema with multiple plaques with adherent scales present over the plaques over the trunk and extremities surmounted by multiple pustules over the abdomen, back, and proximal extremities

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Figure 2: Histopathology showing psoriasiform elongation of rete ridges, suprapapillary thinning, dilated capillaries and parakeratosis, and spongioform pustules of Kogoj (H&E ×10, ×20)

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Figure 3: Hyperpigmented plaques over trunk, lower, and upper extremities

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Figure 4: Response after 3 months showing complete clearing of lesions

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  Discussion Top


Apremilast, a phosphodiesterase-4 inhibitor, prevents the conversion of cyclic adenosine monophosphate (cAMP) to adenosine monophosphate.[1] The resultant increase in cAMP levels modulates the production of proinflammatory and anti-inflammatory mediators. There is a decrease in the pro-inflammatory mediators such as tumour necrosis factor alpha, interleukin-12 and interleukin-23, interferon gamma, and nitric oxide synthase as well as upregulation of anti-inflammatory mediators such as interleukin-10.[2] Studies on apremilast showed few adverse effects.[3] The adverse effects include nausea, vomiting, headache, fatigue, upper respiratory tract infections, musculoskeletal pain, weight loss, mood swings, and suicidal tendencies.[4] With gradual introduction of apremilast, no side effects were seen and the patient cooperated well.

Good safety profile and ease of oral administration without a need of laboratory monitoring makes apremilast a well-sought drug.[5]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Arcilla J, Joe D, Kim J, Kim Y, Truong VN, Jaipaul N Erythrodermic psoriasis treated with apremilast. Dermatol Reports2016;8:6599.  Back to cited text no. 1
    
2.
Thomas J, Srinivasan S Efficacy of apremilast in psoriasis: A cross sectional study. Int J Res Dermatol 2019;5:187-91.  Back to cited text no. 2
    
3.
Bubna AK Apremilast: A dermatologic perspective. Indian J Drugs Dermatol 2016;2:75-82.  Back to cited text no. 3
    
4.
Afra TP, Razmi TM, Dogra S Apremilast in psoriasis and beyond: Big hopes on a small molecule. Indian Dermatol Online J 2019;10:1-12.  Back to cited text no. 4
    
5.
Parasramani S, Thomas J, Budamakuntla L, Dhoot D, Barkate H Real-world experience on the effectiveness and tolerability of apremilast in patients with plaque psoriasis in India. Indian J Drugs Dermatol 2019;5:83-8.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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