Different response rates between palmoplantar involvement and diffuse plaque psoriasis in patients treated with infliximab

ARTICLE

ejd.2011.1567

Auteur(s) : Alexandra Maria Giovanna Brunasso^1,2 giovanna.brunasso@gmail.com, Matteo Puntoni³, Chiara Delfino⁴, Cesare Massone⁵

¹ Department of Enviromental Dermatology and Venereology, Medical University of Graz, Auenbruggerplatz 8, A-8036 Graz-Austria

² Department of Dermatology, Galliera Hospital, Genoa, Italy

³ Department of Oncology and Biostatistical research, Galliera Hospital, Genoa, Italy

⁴ Department of Dermatological Sciences, Florence, Italy

⁵ Department of Dermatology, Medical University of Graz, Auenbruggerplatz 8, A-8036 Graz-Austria

We performed a retrospective study of patients affected by severe plaque psoriasis (PASI>20) with palmoplantar involvement (PPI) who underwent infliximab therapy for more than 24 weeks, in order to describe and compare the clinical response of PPI vs that of plaque psoriasis elsewhere on the body. Clinical charts were reviewed for: demographics, psoriasis severity (Psoriasis Area Severity Index [PASI], m-PPPASI [modified PalmoPlantar Psoriasis Area Severity Index]), treatment (duration, dosages, adverse events) and concomitant treatments (duration and dosages) [1-3]. We used the Mann Whitney test to compare PASI and m-PPPASI improvements.

Five patients treated with infliximab, 3 males and 2 females, with a mean age of 41.4 years, affected by severe plaque psoriasis (mean baseline-PASI: 34) with PPI (mean baseline m-PPPASI: 31.7) were followed for an average of 87.6 weeks. Demographics, severity indexes, adverse events and therapy schedules are reported in table 1.

Table 1 Clinical and therapy summary, evolution measures and adverse events.

Sex: M: male, F: female; PsA: confirmed psoriatic arthritis; CsA: cyclosporine A; Mtx: methotrexate; PUVA: Psoralen + ultraviolet A photo-therapy. Associated therapy: Mtx: methotrexate (5 mg/weekly in patients #1, #2 and #3 and 10 mg/weekly in patient #5).

At week 0, 2, 6 and every 8 weeks thereafter.

At week-14, the mean PASI improvement was 86.8% and the mean m-PPPASI improvement was 27.69% (p: 0.008). At week-30, the mean PASI improvement was 89.11% and the mean m-PPPASI improvement was 41.2% (p: 0.008). Comparative PASI and m-PPPASI score evolutions are shown in figure 1. Mean PASI and m-PPPASI improvements at the last follow-up visit were 80.8% and 44.8% respectively (p:0.03).

We decided to conduct this retrospective study because of the continuous complaints of two patients (patients #4 and #5) who were not satisfied, even if their PASI scores were significantly lower compared to baseline. The patients referred a lower efficacy in the palmoplantar area compared with the rest of the body response, not only for functional and cosmetic reasons but also because the psoriasis stigmata were always visible. Our results confirmed the patients’ theory, the palm and sole improvements were less encouraging than those of the rest of the body. It's worth noticing, that there was no statistically significant difference between the severity of PPI and the severity of diffuse psoriasis involvement comparing PASI and m-PPASI scores at baseline (p:0.8) but when we compared the efficacy at week-14 and week-30, the mean PASI improvements were 86.8% and 89.11% respectively, while the mean m-PPPASI improvements were only 27.69% and 41.2% (p:0.008).

Our knowledge of the use of infliximab in palmoplantar plaque psoriasis is confined to the experience of 27 patients and data comparing the palmoplantar response vs the rest of the body response are lacking [3, 4]. In contrast with our results, Di Lernia et al., published 3 cases affected by diffuse plaque psoriasis with PPI who reported an excellent response (PPPASI: 63- 100%) after 24 weeks of infliximab [4]. A randomized controlled trial (RCT) with 24 patients revealed that only 33.3% of patients achieved an m-PPPASI 75 at week-14, not reaching the primary endpoint of the study [3]. This response of PPI is lower if compared to trials where 75.5- 87.9% of patients with moderate to severe plaque psoriasis achieved a PASI-75 at week-14 [5]. Unfortunately the severity and the response-rate for the diffuse psoriasis were not available in these 27 patients [3, 4].

This report is the first attempt to evaluate and compare the palmoplantar response with the rest of the body response in patients who followed biological therapy. These data become important if we consider that QOL impairment is higher in patients affected by palmoplantar psoriasis compared to psoriasis vulgaris [6].

Our data, together with the efficacy rates shown in the previously mentioned RCT, suggest that, even if infliximab is one of the most effective treatments for severe plaque psoriasis, the effect on the PPI of patients affected by severe diffuse plaque psoriasis seems to be less dramatic [3].

Disclosure

Financial support: none. Conflicts of interest: none.

References

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