Breakthrough Psoriasis in Patients Receiving Biologicals.

Abstract

Background: Biological therapies, including TNF-alpha, IL12/23, IL17 and IL23 antagonists, adequately control a very high number of patients with moderate-to-severe psoriasis with an excellent long-term safety profile. However, on occasion, patients on biological therapy with stabilized disease or complete remission report episodes of sudden breakthrough psoriasis.

Aim: To study prospectively in a monocentric tertiary setting, the clinical characteristics of patients presenting a sudden breakthrough psoriasis although completely stabilized (PASI 90-100) under biological therapy.

Materials and methods: Psoriasis patients treated by biological therapies achieving PASI 90-100 and with stabilized disease for at least 6 months were invited to enter the follow-up study for 5 years. The clinical features of patients presenting a breakthrough psoriasis were described as well as the rescue therapies and outcomes.

Results: From the total cohort of 1121 patients with psoriasis receiving biologicals, 985 patients responded to the inclusion criteria. After 5 years, 10/882 cases (1,13%) of breakthrough psoriasis were identified. Two cases were induced by the Köbner phenomenon and 8 cases by severe psychological stress. Rescue therapies included topical very potent corticosteroids or additional injections of the biological. Two patients recovered spontaneously when the stressful event was resolved. In none of the cases, there was a consistency between the breakthrough event and the next scheduled injection, nor the duration of the exposure to the treatment. No biological class or agent could be systematically incriminated.

Conclusion: Breakthrough psoriasis is an exceptional event among patients with stabilized psoriasis using biologicals, either triggered by the Köbner phenomenon or by severe psychological stress. The pathogenesis of the breakthrough events could be linked to stress- or Köbner-related immunomodulation, permitting breakthrough psoriasis lesions to appear.