Letter - Therapy
Pustular psoriasis triggered by therapy with atezolizumab and bevacizumab
Mariani Magnus da Luz Andrade
, Guilherme Ladwig Tejada, Juliano Peruzzo, Renan Rangel Bonamigo
Corresponding author
Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
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These medications were administered every 21 days and were infused on the same day. During follow-up, the infusion was withdrawn due to hospitalization because of clinical complications. At the time, there was rapid improvement of the lesions, in four weeks (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). After this period, the infusions were resumed, and psoriasis recurred (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B), reinforcing the association between the skin condition and drug administration. The clinical presentation, in the form of erythematous-desquamative plaques with pustules (<a class="elsevierStyleCrossRef" href="#fig0010">Figs. 2</a>A and <a class="elsevierStyleCrossRef" href="#fig0010">2</a> B) and pustule generalization to the trunk (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A), associated with the anatomopathological examination (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B) with intraepidermal pustules and psoriasiform infiltrate, allowed the diagnosis of psoriatic exacerbation, in the form of pustular psoriasis, triggered by antineoplastic immunotherapy. The case constituted a therapeutic challenge since the patient had an hepatocellular carcinoma developed in cirrhosis due to chronic hepatitis C. Therefore, there was contraindication to the use of drugs such as acitretin and methotrexate, due to the risk of severe liver toxicity (including liver failure), and to the use of anti-TNF, considering the diagnosis of hepatitis C. Moreover, the patient developed arthritis in the interphalangeal joints, reinforcing the choice of systemic therapy. Considering these limitations, the authors chose an interleukin (IL-) inhibitor, ustekinumab (anti-IL 12/23).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Interestingly, there have been reports of psoriasis improvement with the use of BVZ.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> Vascular proliferation in the papillary dermis is known to play an important role in the pathophysiology of psoriasis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Moreover, it was found that VEGF levels are higher in psoriatic lesions when compared to healthy skin. Plasma factor levels have also been observed to be higher in patients with psoriasis than in healthy ones.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">On the other hand, ATZ seems to induce a pro-inflammatory state, with a change in the cytokine profile, with an increase in TNF-α and IL-17 levels, which would explain psoriasis onset or worsening.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Skin changes due to ATZ usually occur within five to nine weeks after beginning therapy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In the present case, psoriasis worsening occurred nine weeks after starting therapy, in agreement with the literature. Guttate, inverse, and palmoplantar presentations of psoriasis exacerbations have been described with the use of ATZ.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Therefore, the case highlights the combination related to the eruption, and also the unusual pustular presentation.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0030" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors' contributions</span><p id="par0035" class="elsevierStylePara elsevierViewall">Mariani Magnus Andrade: Collection, analysis and interpretation of data; drafting and editing of the manuscript or critical review of important intellectual content; critical review of the literature.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Guilherme Ladwig Tejada: Collection, analysis and interpretation of data; drafting and editing of the manuscript or critical review of important intellectual content; critical review of the literature.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Juliano Peruzzo: Analysis and interpretation of data; critical review of important intellectual content; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Renan Rangel Bonamigo: Analysis and interpretation of data; critical review of important intellectual content; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors' contributions" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-12-19" "fechaAceptado" => "2023-02-02" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1990 "Ancho" => 2508 "Tamanyo" => 559926 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0390" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Patient showing improvement of psoriasis lesions after withdrawal of atezolizumab and bevacizumab infusion; (B) Patient showed recurrence of psoriatic lesions after a new infusion, as erythematous-desquamative plaques with pustules.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1674 "Ancho" => 2508 "Tamanyo" => 721260 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0395" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Detail of the clinical lesions on the legs, showing erythematous-desquamative plaques with pustules; (B) Dermoscopy showing the pustules.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1670 "Ancho" => 2508 "Tamanyo" => 927762 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0400" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Presence of generalized pustular lesions on the trunk; 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 18 | 3 | 21 |
| 2024 October | 229 | 97 | 326 |
| 2024 September | 209 | 110 | 319 |
| 2024 August | 188 | 137 | 325 |
| 2024 July | 221 | 113 | 334 |
| 2024 June | 202 | 71 | 273 |
| 2024 May | 133 | 70 | 203 |
| 2024 April | 123 | 101 | 224 |
| 2024 March | 105 | 86 | 191 |
| 2024 February | 301 | 109 | 410 |
| 2024 January | 297 | 108 | 405 |
| 2023 December | 77 | 53 | 130 |
| 2023 November | 101 | 78 | 179 |
| 2023 October | 87 | 92 | 179 |
| 2023 September | 59 | 82 | 141 |
| 2023 August | 3 | 2 | 5 |
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