A 59-year-old man with a 19-year history of moderate-to-severe plaque psoriasis was referred to our department in August 2011 due to a flare of erythroderma involving approximately 100% of his body surface area and a Psoriasis Area and Severity Index (PASI) score of 59 (fig. 1a).
He had been previously treated with topical and systemic drugs, such as cyclosporine A and methotrexate that were interrupted for high blood pressure and loss of efficacy, respectively. Without therapy, his psoriasis worsened. Considering the severity of the skin clinical features and his intolerance of conventional systemic therapies, the patient was considered as 'high need' for biological drugs and was treated with efalizumab in December 2003. The patient withdrew from efalizumab treatment in March 2004 for ineffectiveness and the onset of erythroderma. Hospitalization was necessary, and etanercept (50 mg s.c./week) was administered with a good control of the disease from April 2004 until July 2011.
In July 2011, shortly following cataract surgery on the left eye, the patient developed generalized erythroderma with fever (38.5 C). The therapy with etanercept was discontinued, and the patient was treated with systemic corticosteroid therapy (prednisone 50 mg/day) obtaining an unsatisfactory disease control. In August 2011, severe erythroderma and fever associated with chills and pruritus (itching VAS: 90) occurred. Complete laboratory and instrumental tests were performed, including chest X-ray, ECG, QuantiFeron TB-Gold, complete blood count, complete liver profile, creatinine, auto-antibodies (ANA, anti-dsDNA, ENA, LAC, anti-cardiolipin, anti-citrullin), C-reactive protein, tumor markers, hemoculture, and urinoculture; no significant abnormal results were found. We therefore decided to start therapy with ustekinumab 45 mg s.c. (body weight was 82 kg).
After 4 weeks of treatment, the patient showed an excellent and rapid improvement (fig. 1b) with a reduction of the PASI score to 10 and the absence of fever and itching. After 12 weeks of therapy, the patient showed complete resolution of the clinical picture with the presence of only mild scaling and a PASI score of 3 (fig. 1c). Currently, the patient has been undergoing treatment for 12 months, maintaining a PASI score of 75 with no adverse events.