Diacerein in the treatment of chronic plaque psoriasis: A case report

Kalgi Baxi; Drumil Majmundar; Ani Patel; Vidhi Chandibhamar; Nayan Patel; Vidit Majmundar

doi:10.4103/ijdd.ijdd_19_21

CASE REPORT

Year : 2022 | Volume : 8 | Issue : 2 | Page : 79-82

Diacerein in the treatment of chronic plaque psoriasis: A case report

Kalgi Baxi¹, Drumil Majmundar², Ani Patel³, Vidhi Chandibhamar⁴, Nayan Patel⁴, Vidit Majmundar⁵
¹ Department of Dermatology, Smt NHL Medical College and SVP Hospital, Ahmedabad, India
² Department of Orthopaedics, BJ Medical College and Civil Hospital, Ahmedabad, India
³ GMERS Medical College, Gandhinagar, India
⁴ Department of Dermatology, GCS Medical College, Ahmedabad, Gujarat, India
⁵ Saint Vincent General Hospital, Worcester, Massachusetts, USA

Date of Submission	07-May-2021
Date of Decision	22-Jun-2022
Date of Acceptance	29-Nov-2022
Date of Web Publication	5-Jan-2023

Correspondence Address:
Kalgi Baxi
Department of Dermatology, Smt NHL Medical College and SVP Hospital, B2 Block, Dermatology OPD, Ellisbridge, Ahmedabad 380006, Gujarat
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijdd.ijdd_19_21

Abstract

Diacerein belongs to the class of anthraquinone derivatives which has anti-inflammatory, analgesic, and antipyretic properties. The principal mechanism of action of diacerein is to inhibit the interleukin-1β system and related downstream signaling. Several rheumatology societies such as the European League against Rheumatism (EULAR) and the Osteoarthritis Research Society International (OARSI) have introduced diacerein in their therapeutic guidelines as a treatment option in osteoarthritis. We hereby report the case of a 56-year-old man suffering from chronic plaque psoriasis who was prescribed diacerein by an orthopedician for bilateral knee osteoarthritis. We observed a dramatic improvement in the psoriatic skin lesions with the achievement of Psoriasis Area Severity Index 75 at 12 weeks, without objectively observed adverse drug event. This suggests a probable role of diacerein as an oral biological agent in the therapeutic armamentarium of chronic plaque psoriasis

Keywords: Chronic plaque psoriasis, diacerein, interleukin-1β inhibitor

How to cite this article:
Baxi K, Majmundar D, Patel A, Chandibhamar V, Patel N, Majmundar V. Diacerein in the treatment of chronic plaque psoriasis: A case report. Indian J Drugs Dermatol 2022;8:79-82

How to cite this URL:
Baxi K, Majmundar D, Patel A, Chandibhamar V, Patel N, Majmundar V. Diacerein in the treatment of chronic plaque psoriasis: A case report. Indian J Drugs Dermatol [serial online] 2022 [cited 2023 Oct 1];8:79-82. Available from: https://www.ijdd.in/text.asp?2022/8/2/79/367118

Introduction

Diacerein belongs to the class of anthraquinone derivatives which has anti-inflammatory, analgesic, and antipyretic properties.^[1] The principal mechanism of action of diacerein is to inhibit the interleukin-1β (IL-1β) system and related downstream signaling.^[2] Several rheumatology societies such as the European League against Rheumatism (EULAR) and the Osteoarthritis Research Society International (OARSI) have introduced diacerein in their therapeutic guidelines as a treatment option in osteoarthritis.^[3] Interleukin-1α (IL-1α) and IL-1β, the two major subunits of IL-1, are implicated in the pathogenesis of plaque psoriasis.

We hereby report the case of a 56-year-old male patient with moderate chronic plaque psoriasis, responding to diacerein which was prescribed by an orthopedician for bilateral knee osteoarthritis.

Case Report

A 56-year-old male patient was referred to the dermatology outpatient department for chronic plaque psoriasis of 10 years’ duration. The patient also had concurrent bilateral knee osteoarthritis, as diagnosed by the orthopedician. There was no history of any other medical or surgical comorbidities. The patient had been consulting local doctors for psoriasis and was on intermittent topical therapies.

Cutaneous examination revealed multiple, discrete erythematous, scaly plaques over the dorsa of feet, extensor aspects of legs, thighs, lower back, elbows, and scalp, involving nearly 10% body surface area [Figure 1], with a baseline psoriasis area severity index score of 9.8. Nail involvement was present in the form of multiple coarse irregularly arranged pits on multiple finger nails with focal onycholysis.

Figure 1: Baseline clinical photographs: Multiple erythematous plaques with silvery white coarse scaling

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The patient had been prescribed by the orthopedician a dose of 100 mg/day of diacerein tablet for the treatment of osteoarthritis of knee. Based on preliminary data of efficacy of diacerein in plaque psoriasis, the patient was prescribed only supportive treatment in the form of emollients and oral antihistaminics for psoriasis and monitored every 4 weeks for a total period of 16 weeks. [Table 1] shows the decline in Psoriasis Area Severity Index (PASI) value at monthly follow-up, with achievement of PASI 75 at week 12, showing regression of erythema, induration, and scaling in the plaques. [Figure 2] shows the follow-up clinical photographs of the patient at week 8.

Table 1: Change in PASI score

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Figure 2: (A, B, C): Reduced erythema, induration, and scaling at weeks 8, 12, and 16 respectively

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At week 12, diacerein was stopped by the orthopedician. [Figure 3] shows the clinical photographs of the patient at the end of the diacerein therapy. The patient followed up for up to 8 weeks after stopping diacerein, without significant recurrence of psoriatic plaques, and then was lost on follow up.

Figure 3: (a,b):A: Pre-treatment ,B: Post Diacerein therapy at week 16

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Discussion

We conducted an online search with the keywords “Diacerein”, “Chronic Plaque psoriasis”, and “Osteoarthritis”. Diacerein, an IL-1β antagonist, has been approved since 2008 for use in osteoarthritis. Over the recent years, newer medical indications of diacerein such as Type 2 diabetes mellitus are under investigation. Topical 1% diacerein cream is found to be effective in recalcitrant plaque psoriasis, and has been recently approved by the Food and Drugs Administration (FDA) for epidermolysis bullosa simplex.^[4] Based on the review of available literature, the authors found a single study of use of diacerein in plaque psoriasis in 7 patients. The study has been carried out in 2003, in Europe, wherein all the patients showed a clinical response^[5] (available from: https://patents.google.com/patent/EP1248608B1/en). In 2017, Mohan et al.^[6] explained in detail the theoretical efficacy of this drug on cutaneous and systemic inflammatory milieu in psoriasis by inhibition of IL-1. A major side effect of diacerein is diarrhea (incidence of 46%),^[7] usually maximum at the first 2 weeks and stops on continuing treatment. It is reversible after cessation of treatment. Other side effects include abdominal pain, nausea (chiefly due to incomplete absorption of “Rhein” moiety which is a metabolite of diacerein) and urine discoloration, and reactivation of latent tuberculosis. Contraindications of diacerein include severe hepatic and renal failure, pregnant and lactating females as well as patients aged less than 15 years.

IL-1α and IL-1β, the two major subunits of IL-1, are implicated in psoriasis pathogenesis. Increased expressions of IL-1α and IL-1β have been found in psoriatic lesional skin in mouse models and in human subjects, as these cytokines directly contribute to the inflammation present in the skin.^[8],[9],[10] Also recent studies indicate that the inflammation in psoriasis is not just limited to the skin, but is also associated with IL-1-driven systemic inflammation. Increased local levels of IL-1 in turn lead to an increase in proinflammatory mediators secreted by the activated keratinocytes, and thus contribute to epidermal inflammation. Also, IL-1 stimulates IL-17 and IL-23 production in T-cells,^[11],[12] which are the main proinflammatory cytokines in the dysregulated cutaneous immune system in a psoriatic skin lesion.

Immunomodulatory agents are the conventional therapy for plaque psoriasis, with years of experience in terms of therapeutic efficacy as well as safety profile. However, regular monitoring of various hematological parameters is required in patients on these agents.

Biologicals are an excellent choice for management of psoriasis even in combination with the conventional therapy. However, financial burden is a major limiting factor, especially in a country like India.

Being a small molecule with a mechanism of action similar to a biological, diacerein would theoretically be an “affordable” substitute to a biological. Moreover, based on multiple systematic meta-analyses and trials which have been carried out for this drug in osteoarthritis, it can be concluded that it is a relatively safe drug, without major side effects, and also has a possible “carry over” effect, that is, continued therapeutic efficacy after stopping treatment. Also, no monitoring guidelines have been recommended for this drug in osteoarthritis.

Diacerein might have a therapeutic role for patients with moderate to severe plaque psoriasis, pending systematic trials and case studies. However, its therapeutic efficacy as a standalone agent for psoriasis is still debatable, due to a very limited available literature. In a specific subgroup of psoriatic patients with coexisting hip and knee osteoarthritis, diacerein may be a viable option, even as an adjuvant to topical therapy. We did not use any other systemic agent for treatment of chronic plaque psoriasis in our patient which could have affected the course and outcome of cutaneous lesions; hence, the outcome or clinical response in our patient could be attributed to diacerein alone.

The chief limitation of this report is lack of a long-term follow-up for observing recurrence. Moreover, diacerein is reported to be effective in knee and hip osteoarthritis, without valid supporting data regarding arthritis of other causes. Hence, studies of efficacy of diacerein on various patient profiles are mandated to explore its safety and efficacy in plaque psoriasis and psoriatic arthritis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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