Coexisting bullous pemphigoid and psoriasis successfully treated with etanercept

ARTICLE

Auteur(s) : Francesco Cusano¹, Silvia Saletta Iannazzone¹, Giacomo Riccio², Fabio Piccirillo¹

¹Dermatology Unit, “Gaetano Rummo” General Hospital
²Dermatology Unit, Terme di Telese, Via dell'Angelo 1, 82100 Benevento, Italy

Psoriasis is occasionally accompanied by bullous diseases and the role of TNF-α in the pathogenesis of both is well known [1].

A 49-year-old woman with a long history of psoriasis was treated in another dermatological unit with topical therapies and UVB phototherapy. In May 2006, the skin lesions worsened; cyclosporine 3 mg/kg/d did not give significant results, nor did methotrexate 10 mg weekly and NB/UVB phototherapy. Moreover, some bullae appeared on her chest and a skin biopsy showed results consistent with bullous pemphigoid (BP). In October 2006, prednisone 50 mg/d was started, with complete clinical clearing of BP and improvement of the psoriasis; after 6 weeks, it was progressively tapered down to a minimum dose of 5 mg twice a week and finally stopped in May 2008. Unfortunately, after about 8 weeks, without any topical or systemic medication both the BP and psoriasis rapidly relapsed, and the patient was referred for the first time to our Unit.

Physical examination revealed plaque-type psoriasis with a PASI of 17.2 and scattered bullous lesions on an erythematous background (figure 1A). A new skin biopsy, histology and direct immunofluorescence confirmed the diagnosis of BP. Due to previous side effects (particularly, increased body weight), the patient refused steroid treatment. Therefore, according to positive preliminary experiences with combined therapies including TNF-α antagonists in the treatment of coexisting BP and psoriasis [2, 3], etanercept 100 mg weekly was started, with the eventual aim of introducing steroids later. Surprisingly, while the psoriasis slowly improved, the BP cured dramatically in just a few days. After 12 weeks’ treatment, all the skin symptoms almost completely disappeared (absence of bullae and PASI 1.3; figure 1B), and it was reduced to 50 mg weekly. At a 16 week follow-up, the patient was almost free of skin lesions but, 2 weeks later, a severe outbreak of a new morphology of lesions was observed, with erythematous plaques on her legs and soles, pustules (figure 1C), leg edema and pain on the knees and ankles. A skin biopsy was performed and the histological examination concluded that the intra-epidermal sterile pustules were compatible with pustular psoriasis; therefore acitretine 0.5 mg/kg/d was added and the rash progressively improved in 8 weeks; the dosage was subsequently reduced and finally stopped after a further 12 weeks. At a 6 week follow-up after acitretine was withdrawn, the BP and psoriasis were in remission and etanercept was stopped. After a further 12 weeks, the patient showed a slight recurrence of psoriasis (PASI of 4.5), managed with topical drugs.

We describe a patient in whom remission of BP was obtained with etanercept used as a single drug therapy. In the literature, 2 cases of BP [2, 3] treated with etanercept are described, both coexisting with psoriasis; the first achieved remission using etanercept when the steroid dose was lowered [2], the second patient was given etanercept for psoriasis after being completely cured of BP with rituximab [3].

Surprisingly, our patient's BP was better controlled than her psoriasis. In fact, after 18 weeks of treatment with TNF-α blockers, an erythemato-pustular rash was observed on the legs and feet. The occurrence of palmoplantar pustulosis during TNF-blocking therapy [4], or a relapse after steroid withdrawal, or a pustular psoriasis following BP [5, 6], were hypothesized. In our case, the rash did not require stopping the TNF blocking therapy.

In conclusion, the literature and our case show that TNF-α antagonists might represent an effective alternative therapy for co-existing BP and psoriasis, since corticosteroids may induce a relapse of psoriasis and other well-known side effects, and traditional systemic therapies are often associated with organ toxicity. Further studies are needed to establish the efficacy of anti-TNF in the treatment of other immunobullous disorders.

Acknowledgements

References

2 Yamauchi PS, Lowe NJ, Gindi V. Treatment of coexisting bullous pemphigoid and psoriasis with the tumor necrosis factor antagonist etanercept. J Am Acad Dermatol 2006; 54 (3 Suppl 2): S121-S122.

3 Saraceno R, Citarella L, Spallone G, Chimenti S. A biological approach in a patient with psoriasis and bullous pemphigoid associated with losartan therapy. Clin Exp Dermatol 2008; 33: 154-5.

4 Ko JM, Gottlieb AB, Kerbleski JF. Induction and exacerbation of psoriasis with TNF-blockade therapy: A review and analysis of 127 cases. J Dermatolog Treat 2009; 20: 100-8.

5 Yasukawa S, Dainichi T, Kokuba H, et al. Bullous pemphigoid followed by pustular psoriasis showing Th1, Th2, Treg and Th17 immunological changes. Eur J Dermatol 2009; 19: 69-71.

6 Miyakura T, Yamamoto T, Tashiro A, et al. Anti-p200 pemphigoid associated with annular pustular psoriasis. Eur J Dermatol 2008; 18: 481-2.