Treatment of Acrodermatitis Continua of Hallopeau with TNF-Blocking Agents: Case Report and Review

Abstract

Acrodermatitis continua of Hallopeau (ACH) is a rare acropustular eruption, characterized by sterile pustules, paronychia and atrophic skin changes, onychodystrophy and osteolysis of the distal phalanges of the fingers and toes. It is considered to be a variant of pustular psoriasis with a chronic relapsing course and frequent refractoriness to many therapeutic modalities, which can be amenable to successful treatment by tumor necrosis factor α antagonists. We report 1 patient with pustular psoriasis and ACH whom we have treated successfully with etanercept (for 30 months) and then adalimumab (for 13 months and ongoing). Blanching was initially achieved with etanercept 50 mg twice a week, but suppression of periungual inflammation then required combination therapy with etanercept 50 mg twice a week and methotrexate 10 mg weekly; lower doses of both drugs did not allow complete control of the disease. Eventually, adalimumab 40 mg every 2 weeks has provided the most cost-effective response in this patient, allowing maintenance of response with partial nail regrowth under monotherapy.

Acrodermatitis Continua of Hallopeau Treated Successfully with Ustekinumab and Acitretin after Failure of Tumour Necrosis Factor Blockade and Anakinra

“…Though anti-tumour necrosis factor (TNF) can induce palmoplantar pustular psoriasis (PPPP), it has been proven efficient for ACH. The results of 33 treatments with anti-TNF in 23 ACH patients have been reported so far [2,3,4,5,6,7]. In responsive patients, clearance of lesions was reported to occur more rapidly than in psoriasis vulgaris.…”

Pustular psoriasis and related pustular skin diseases

“…Differently from GPP, patients with PPPP are not at risk of developing life‐threatening complications, which remain a hallmark of GPP and of AGEP. However, palmar and/or plantar pustular involvement may associate with acropustular (ACH) presentation . Furthermore, some recent observations indicate that in patients with deficiency of interleukin‐36 receptor antagonist (DITRA), a localized initial phase of the disease may be followed by GPP attacks, emphasizing the complexity of genotype–phenotype correlation .…”

“…The acropustular pustular subtype of psoriasis is very rare, and is of a sporadic nature . However, it is interesting to notice that chronic ACH lesions have been reported to persist in between the systemic attacks in patients with GPP, including those with DITRA .…”

Off-Label Dermatological Uses of Etanercept Treatment

“…Eventually, adalimumab 40 mg every 2 weeks has provided the most costeffective response in this patient, allowing maintenance of response with partial nail regrowth under monotherapy. Bonish et al also observed a case of etanercept responsive acrodermatitis continua of Hallopeau [12,13].…”