Treatment of erythrodermic psoriasis: From the medical board of the National Psoriasis Foundation
Accepted 14 May 2009. published online 10 August 2009.
Background
Erythrodermic psoriasis is a severe form of psoriasis that can arise acutely or follow a chronic course. There are a number of treatment options, but overall there are few evidence-based data to guide clinicians in managing these challenging cases.
Objective
Our aim was to create treatment recommendations to help dermatologists treat patients with erythrodermic psoriasis.
Methods
A task force of the National Psoriasis Foundation Medical Board was convened to evaluate treatment options for erythrodermic or exfoliative psoriasis. Meetings were held by teleconference and were coordinated and funded by the National Psoriasis Foundation. Consensus on treatment of erythrodermic psoriasis was achieved. A literature review was conducted to examine treatment options for erythrodermic psoriasis and the strength of the evidence for each option.
Results
There is no high-quality scientific evidence on which to base treatment recommendations. Treatment should be dictated by the severity of disease at time of presentation and the patient's comorbidities. Cyclosporine and infliximab appear to be the most rapidly acting agents for the treatment of erythrodermic psoriasis. Acitretin and methotrexate are also appropriate first-line choices, although they usually work more slowly. Treating physicians can consider a number of second-line agents, including etanercept or combination therapy, in the treatment of patients with erythrodermic psoriasis. Combination therapy may be more effective than a single-agent approach; there is a paucity of scientific data in this area. All patients should be evaluated for underlying infection. Supportive care can help control disease and patient symptoms if instituted appropriately. Physicians should avoid potential exacerbating agents when managing this challenging disease.
Limitations
There are few high-quality studies examining treatment options for erythrodermic psoriasis.
Conclusion
Treatment of patients with erythrodermic psoriasis demands a thorough understanding of the treatment options available. Therapy should be based on acuity of disease and the patient's underlying comorbidities. There are limited data available to compare treatment options for erythrodermic psoriasis. Further studies are necessary to explore the optimal treatment algorithm for these patients.
aDepartment of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
bDepartment of Dermatology, Baylor College of Medicine, Houston, Texas
cDepartment of Dermatology and the Murdough Family Center for Psoriasis, Case Western Reserve University/University Hospital of Cleveland, Cleveland, Ohio
dDepartment of Dermatology, Mount Sinai School of Medicine, New York University, New York, New York
Reprint requests: Abby S. Van Voorhees, MD, Hospital of the University of Pennsylvania, 2 Rhoads, 3400 Spruce St, Philadelphia, PA 19104.
Supported by the National Psoriasis Foundation.
Disclosure: Dr Van Voorhees has received grant support from Amgen, Astellas, and Warner Chilcott. She has been a consultant, advisory board member, or speaker for Amgen, Centocor, Connetics, Genentech, and Warner Chilcott and a drug safety monitoring board member for Synta. She is a major stockholder in Merck. Dr Hsu has been a consultant for Abbott, Amgen, Biogen Idec, Centocor, and Genentech. She has been a clinical investigator for Amgen and Centocor. Dr Korman has been a consultant, investigator, or speaker for Abbott, Amgen, Astellas, Centocor, and Genentech. Dr Lebwohl has been a consultant for Abbott, Amgen, Astellas, Centocor, Genentech, UCB Pharma, Stiefel, Triax, Pharmaderm, Medicis, Novartis, and Warner Chilcott. He has been a speaker for Abbott, Amgen, Astellas, Centocor, and Genentech. Ms Young has served on the advisory board or been a speaker for Abbott, Amgen, Astellas, Centocor, and Genentech. Dr Bebo is employed by the National Psoriasis Foundation. The foundation receives unrestricted financial support from Abbott, Centocor, Amgen, Wyeth, Genentech, Astellas, Stiefel, Galderma, Warner Chilcott, and Photomedix. Dr Rosenbach has no conflicts of interest to declare.
Consensus: The medical board of the National Psoriasis Foundation reviewed and endorsed this manuscript by a majority vote.
ABSTRACT