Case Reports Support Use of IL-23 Inhibitors to Treat Psoriasis in Cancer Setting

Interleukin-23 (IL-23) inhibitors may be a safe option to treat psoriasis in patients with active cancer, according to a new report.

The report is based on a 3-case series that found IL-23 inhibitors were effective against psoriasis. The report was published in SAGE Open Medical Case Reports.

Immune checkpoint inhibitors (ICIs) have had a major impact on cancer care, but they can also lead to immune-related adverse events (irAEs), noted the study authors from the Princess Margaret Cancer Centre, in Toronto, Ontario, Canada. Among the most common AEs is immune-related psoriasis, which the investigators said can be difficult to treat in patients with cancer.

In the new report, the authors describe 3 patients with cancer who were given IL-23 inhibitors for psoriasis or immune-related psoriasis.

The first patient, a 52-year-old male with metastatic non–small cell lung adenocarcinoma that was BRAF G469A mutated with high programmed death-ligand 1 expression, was enrolled in a clinical trial in which he received a MEK inhibitor and the monoclonal antibody pembrolizumab (Keytruda). The patient had to leave his clinical trial due to the development of psoriasis and psoriatic arthritis. He was treated with guselkumab (Tremfya) and prednisolone. His psoriasis improved and he eventually had a partial cancer response to chemotherapy and pembrolizumab, the authors said.

The second patient was a 58-year female with BRAF-mutated metastatic melanoma who developed pyrexia and psoriasis flares while on first-line targeted therapy. The patient had been prescribed dabrafenib (Tafinlar) and trametinib (Mekinist), but she was hoping to switch to immunotherapy due to cancer progression and medication intolerance, the authors said. Guselkumab led to improvement in her psoriasis, but her cancer eventually progressed despite treatment, ultimately taking her life.

The final patient was a 60-year-old man with metastatic BRAF-mutated melanoma who underwent radiation and 2 cycles of combination immunotherapy that was complicated by colitis and arthritis. His initial therapy led to a partial response in his brain metastasis and a complete response in his lymph nodes. His adverse events were managed using several medications, including infliximab (Remicade). After 6 months, he was given nivolumab (Opdivo) monotherapy, which was discontinued due to a severe colitis flare. A subsequent progression of his brain metastasis was treated with surgery and radiation followed by targeted therapy. Psoriasis developed and eventually became severe, with palmoplantar pustulosis. He discontinued infliximab and started on risankizumab (Skyrizi). His psoriasis improved, but after 5 months on risankizumab his brain metastases progressed.

The authors said managing psoriasis in a cancer setting is a clinical challenge.

“There is a lack of effective, safe, and evidence-based treatment options and guidelines,” they said.

Topical therapies, phototherapy, and the oral treatment acitretin can be used without affecting immunotherapy, but the authors said the use of low-dose methotrexate and immunosuppressive medications remains controversial and warrants further investigation.

The authors said their experience in these 3 cases suggests IL-23 inhibitors hold promise.

“IL-23 inhibitors, by being immunomodulator instead of immunosuppressive, may be a safe option to treat psoriasis in an active cancer setting for moderate-to-severe irAEs,” they said. “There is a need for further research with prospective trials evaluating IL-23 inhibitors in an active cancer setting and in the setting of immune-related psoriasis.”

Reference

Fournier C, Butler MO, Sauder MB. The use of interleukin-23 inhibitors to treat immune-related psoriasis induced by immune checkpoint inhibitors and in patients with active cancer: a case series and review of the literature. SAGE Open Med Case Rep. Published online June 16, 2023. doi:10.1177/2050313X231181035