Rapid Clearance of Recalcitrant Psoriasis With an IL-17 Inhibitor
Mark Lebwohl, MD, presents a case of a 48-year-old female with a 10-year history of psoriasis who was successfully treated with an IL-17 inhibitor after inadequate response to both phototherapy and a TNF blocker.
By Mark Lebwohl, MD
A new female patient in her 40s presented to the clinic with plaque psoriasis on the legs and buttocks.
The patient had a 10-year history of uncontrolled psoriasis with steadily worsening symptoms. She stated that she often felt anxious and uncomfortable in social situations given the noticeable plaques on her legs. This led to feelings of isolation and loneliness in addition to the physical discomfort from the numerous plaques.
She expressed frustration as a result of previous failed treatments and agreed to participate in a stage IV clinical trial of ixekizumab that required weekly photographs to capture symptom improvement.
Medical History, Physical Exam, and Lab Results
Examination revealed sharply demarcated scaling plaques on the legs and buttocks.
The patient was assessed as having a body surface area (BSA) score of 30%, which is classified as very severe, and a Psoriasis Area and Severity Index (PASI) score of 19, also classified as severe. The patient denied joint pain and did not have hypertension or diabetes.
A QuantiFERON test was performed to rule out active and latent tuberculosis (TB) infection; results were negative.
The patient’s hepatitis profile was normal, and complete blood count, chemistry screen, and lipid screen were within normal limits.
Due to the patient’s history, reported symptoms, and the presence of sharply demarcated scaling plaques, a clinical diagnosis of psoriasis was straightforward.
Which class of drugs most rapidly clears psoriasis?
Before & After Photos
Treatment Discussion and Outcome
While this patient’s diagnosis was straightforward, treatment options required some additional thought.
While phototherapy and TNF blockers should be considered as first-line treatments for plaque psoriasis, the patient previously failed to respond favorably to phototherapy and had an inadequate response to adalimumab.
The patient expressed frustration at the lack of response to these treatments and iterated that she was seeking options that would produce results quickly. Since she did not test positive for active or latent TB and her hepatitis profile was normal, it was determined that ixekizumab was the best treatment option for this patient.
The patient was started on ixekizumab 80 mg twice per day at week 0, followed by 80 mg once per day at weeks 2, 4, 6, 8, and 12. The patient began seeing positive results at one-week follow-up.
By week 4, the patient had achieved PASI 75 (a 75% decrease from baseline) and a static Physician’s Global Assessment (sPGA) of 2. By week 12, the patient maintained PASI 75 and her sPGA had decreased to 1.
As with all biologics, this treatment carries with it the risk of increased granulomatous infections, mainly TB. For patients taking ixekizumab, a QuantiFERON test should be repeated yearly; an annual chemical screen, CBC, and lipid screen are also recommended.
After years of worsening symptoms and inadequate response to other treatments, this patient expressed extreme satisfaction at the rapidity with which she began seeing results on ixekizumab and noted marked improvements to her mental health, self-image, and social life.
Medical Dermatologist Sacramento/Rocklin, CA
Mark Lebwohl, MD Professor and Chairman Department of Dermatology Icahn School of Medicine at Mount Sinai