Exacerbation of Pityriasis Rubra Pilaris under Efalizumab Therapy

Abstract

A 60-year-old woman, diagnosed as having psoriasis vulgaris in 2004 and unresponsive to standard therapies, received weekly subcutaneous injections with efalizumab. Within 9 weeks of treatment a massive aggravation of skin lesions occurred with widespread orange-tinged erythroderma, islands of normal skin on the back and the inner side of the forearms and palmoplantar hyperkeratosis. A biopsy confirmed the clinical diagnosis of pityriasis rubra pilaris. After discontinuation of efalizumab and treatment with oral corticosteroids, acitretin (30 mg/day) and PUVA therapy, the skin lesions continuously improved. Efalizumab, a fully humanized monoclonal antibody against CD11a, inhibits various T cell processes important in the pathogenesis of psoriasis. Efalizumab has been approved for the treatment of moderate to severe psoriasis, but there are no reports in the literature on the use of efalizumab for pityriasis rubra pilaris.

Infliximab monotherapy as first-line treatment for adult-onset pityriasis rubra pilaris: Case report and review of the literature on biologic therapy

“…13,14 The T cell modulator efalizumab has been suggested to improve the disease in a 10-year-old boy unresponsible to multiple common therapies 15 but to exacerbate it in an adult patient. 16 In summary, the above listed cases with TNF-a inhibitors propose a significant response to anti-TNF-a therapy when used in combination therapy and/or in pretreated patients. Our patient was started on infliximab monotherapy during the acute onset stage of the disease without any previous or adjunctive therapy in order to evaluate the clinical effects of anti-TNF-a treatment alone.…”

Pityriasis Rubra Pilaris with Preceding Cytomegalovirus Infection

“…Some viral or bacterial infection may produce modification of immune responses and inflammation of skin as a target, and may lead to the development of PRP. This hypothesis could be supported with a recent report of PRP exacerbated by efalizumab (a monoclonal antibody against CD11a) therapy, an immunosuppressant used for psoriasis vulgaris [10], and topical use of imiquimod, an immune response modifier used for various cutaneous viral diseases and cancers [11]. …”

Effectiveness of Infliximab in Pityriasis Rubra Pilaris Is Associated with Pro-Inflammatory Cytokine Inhibition

“…To date, 20 patients with PRP have successfully been treated with infliximab [9,13,14,15,16,22,25], 10 with etanercept [10,12,21,22,23], 7 with adalimumab [8,11,18,20,26] and 2 with ustekinumab [17,19]. Treatment with biologics was found ineffective in only 2 patients with PRP: 1 patient treated with efalizumab [27] and another treated with infliximab and acitretin [28]. Apart from these latter 2 cases, the clinical response to biologics in patients with PRP was satisfactory in all cases within 2-12 weeks of treatment, without further recurrence.…”