Patients With Refractory Psoriasis Helped by Combination Therapy, Case Study Finds

A set of case studies indicates using acitretin (Soriatane) in combination with secukinumab (Cosentyx) may benefit patients with difficult-to-treat psoriasis.

In a paper published by Dermatologic Therapy, clinicians in Turkey presented 3 cases showing the potential of acitretin in combination with secukinumab, resulting in nearly complete or total relief.

Secukinumab is the first biologic that inhibits interleukin-17A and has demonstrated rapid and long-lasting effectiveness in treating moderate-to-severe psoriasis. Yet there are instances where even increasing the dosage fails to provide a clinical response. The most common sites of recalcitrant psoriasis in patients treated with biologics are the anterior lower legs (49.3%), elbows (35.6%), and posterior lower legs (24.7%)

Acitretin is an oral retinoid derived from vitamin A with a history of use alone or in combination with phototherapy. It is the only systemic therapy for psoriasis that is not immunosuppressive, although it is not suitable for in women of childbearing age. It should be used in low doses due to common adverse effects including chapped lips, dryness of the nose and eye, hair loss, and hyperlipidemia.

Methotrexate is used by clinicians in most combination regimens with biologics, the authors said, but acitretin may be a good alternative with lower potential liver toxicity. In the absence of data evaluating the combination of secukinumab and acitretin, the authors presented a case series of patients with different types of psoriasis: chronic plaque, generalized pustular, and erthryrodermic. The patients each had multiple comorbidities and failed to respond to several conventional and biologic therapies, including escalated secukinumab in 2 patients.

The first case was a 64-year-old woman with a 13-year history of chronic psoriasis (PsO) and peripheral psoriatic arthritis (PsA). She also had type 2 diabetes (T2D), obesity, hypertension, and fatty liver disease complicated by liver fibrosis. The patient had generalized plaque lesions with a score of 29.6 on the Psoriasis Area and Severity Index (PASI) upon initiation of secukinumab at a dose of 300 mg/week for 4 weeks. The authors said skin and joint symptoms improved remarkably, but residual plaques on the forearms and shins persisted despite adding a topical steroid and keratolytic agent.

Within a year, despite significant improvement and a dose escalation of secukinumab, plaques persisted. Four weeks after adding acitretin 25 mg/day (0.3 mg/kg) to secukinumab, the plaques significantly improved without any adverse events. Regression of the lesions continued after 6 months.

The second case was a 37-year-old male with 20-year history of severe chronic PsO accompanied by intermittent erythrodermic attacks. She also had obesity, fatty liver disease, gout, and PSA with axial and peripheral involvement. At week 12, having been treated with 300 mg of secukinumab, his PASI score decreased by 50%-75% (PASI 12). However, at week 16, his PASI score worsened to 17.4. Escalation of the dose to every 2 weeks failed to achieve a response, with infiltrated plaques on the distal extremities persisting. Six weeks of acitretin (25 mg/every other day; 0.1 mg/kg) resulted in significant improvement, and after a year, there were no new lesions or adverse events.

The third case was a 76-year-old male with a 10-year history of chronic PSO and intermittent pustular attacks that often occurred after recurrences of leg cellulitis. He also had T2D, chronic obstructive pulmonary disease, hypertension, atrial fibrillation, obesity, and fatty liver disease.

Acitretin (50 mg/day) was started but discontinued after triple elevations of liver enzymes. After a brief trial of ustekinumab (Stelara), acitretin was reinstated at 25 mg/day; 0.25 mg/kg), yet pustular lesions progressed to widespread plaques. Adding in secukinumab, however, completely cleared the skin at 24 weeks with no side effects. He remained lesion-free after a year.

Reference

Polat Ekinci, A, Bölük, KN, Babuna Kobaner, G. Secukinumab and acitretin as a combination therapy for three clinical forms of severe psoriasis in multi‐drug refractory patients: A case series of high efficacy and safety profile. Dermatol Ther. 2021; 34:e14704. doi: 10.1111/dth.14704