Ustekinumab: effective in a patient with severe recalcitrant generalized pustular psoriasis

Conflicts of interest: E.D. has been an advisory board member and consultant, received grants, research support and honoraria for speaking, or participated in clinical trials, with Abbott, Astellas, Biogen, Centocor Ortho Biotech Inc., Galderma, Glaxo, Janssen‐Cilag, Leo Pharma, Merck‐Serono, Novartis, Pfizer, Schering‐Plough, Stiefel, Wyeth Pharmaceuticals and 3M. A.G.‐D. has been an advisory board member and consultant, and received research support from Abbott and Serono. The other authors declare no conflicts of interest. Madam, Generalized pustular psoriasis is a rare and disabling variant of psoriasis. Its treatment is often challenging, as an unsatisfactory response is frequent. Ustekinumab, a fully human monoclonal antibody that binds to the shared p40 subunit of interleukin 12/23, has proven to be effective and safe for the treatment of moderate‐to‐severe plaque‐type psoriasis.1–4 A 47‐year‐old man presented with recurrent episodes of widespread and often generalized flares of classic plaque‐type psoriasis, which he had experienced since the age of 14. His medical history included hypertension, dyslipidaemia, hyperuricaemia and depression. His psoriasis was first treated with multiple topical agents, etretinate, acitretin, retinoids with psoralen plus ultraviolet A and methotrexate, with only partial response. In February 2007, he started treatment with infliximab, achieving an almost complete clearance of the plaques. However, withdrawal of the drug after seven infusions was necessary because of an elevation of transaminases up to six times the baseline values. Efalizumab was then initiated, but owing to only a slight improvement with this drug and the suspension of commercialization, therapy was withdrawn. A gradual deterioration of his skin involvement led, one and a half months later, to a significant flare of pustular psoriasis. Physical examination was remarkable for diffusely scattered pruriginous pustules on an erythematous base involving his head, trunk and upper/lower limbs (Fig. 1). A biopsy showed the characteristic findings of pustular psoriasis. Complementary tests were normal or negative except for a slight increase in cholesterol and triglycerides. His weight was 92 kg. The baseline situation was as follows: Psoriasis Area and Severity Index (PASI) score modified for pustular psoriasis manifestations (scaling substituted by pustules) 23·3; body surface area (BSA) 25%; Physician’s Global Assessment (PGA) very severe; visual analogue scale (VAS, 0–10) for pruritus 7.