A Remarkable Result after a Lifetime of Disappointment in the Treatment of Severe, Recalcitrant Psoriasis
Case author Danna Calder, MMSc, PA-C presents a case of a 34-year-old male with severe, recalcitrant psoriasis achieving remarkable improvement after decades of treatment challenges.
By Danna Calder, MMSc, PA-C
Case presentation and medical history summary
A 34-year-old White male presented to the clinic with a 20+ year history of psoriasis with onset at puberty. Recently relocating to the area, the patient reported inconsistent use of psoriasis medications, stating, “they never really help anyway.”
He described a significant worsening of his psoriasis, which was now causing extensive pain, itching, and burning. These symptoms contributed to mild depression and impaired his ability to engage in physical exercise. The patient expressed a need for rapid symptom relief.
The patient denied any history of morning stiffness, joint swelling, tenderness, or redness, apart from a single episode of elevated serum uric acid and podagra, diagnosed as gouty arthritis many years prior.
Medical history
The patient has a history of the following:
- Chronic low testosterone: Managed with testosterone pellets
- Bladder spasm and incontinence: Treated with mirabegron
- Attention deficit disorder: Managed with generic Adderall
- Gout: Untreated
For psoriasis, the patient reported trying and failing multiple treatments over the years, including:
- Topical therapies: Various classes of topical steroids, calcipotriene (with and without steroids), and tacrolimus
- Phototherapy: Narrowband UVB and excimer laser
- Systemic therapies: Acitretin and possibly methotrexate (uncertain)
- Biologics: Etanercept, adalimumab, ustekinumab, secukinumab, and ixekizumab
- Oral small molecules: Apremilast
He stated that each medication was used for a minimum of 4 months without achieving meaningful improvement before being discontinued and replaced with another treatment. Some medications were used for longer when his schedule prevented timely follow-up with his dermatology provider.
Physical exam and lab results
At the initial office visit, the patient exhibited erythroderma on the trunk and erythematous, well-demarcated plaques with coarse micaceous scale on the scalp, face, arms, and legs, involving 80% to 90% of body surface area (BSA). Blood pressure readings were elevated, recorded at 156/101, 140/100, and 167/106.
Given concerns about possible secondary impetiginization, the patient was prescribed a one-pound jar of triamcinolone and cephalexin. He was provided a lab slip for complete blood count, comprehensive metabolic profile, hepatitis B and C panels, HIV screening, QuantiFERON-TB Gold, hemoglobin A1c, lipid profile, uric acid, and urinalysis.
Additionally, the patient was referred to a primary care provider (PCP) for a full physical examination, initiation of antihypertensive therapy, and management of gout. Follow-up was scheduled for one week to reassess blood pressure, review laboratory results, and begin cyclosporine therapy.
One week later, the patient reported no notable improvement in his psoriasis. Blood pressure remained persistently elevated. The patient was unable to secure a timely appointment with a PCP. As an interim measure, he was started on lisinopril 40 mg daily and instructed to monitor his blood pressure readings daily.
At the subsequent visit, one week later, the patient’s blood pressure had decreased to 114/72. Laboratory results were reviewed, and he was started on cyclosporine at a dose of 3 mg/kg/day.
The following week, laboratory testing revealed elevated uric acid levels; the patient was referred to his PCP for management. Blood pressure remained stable at 128/76; however, there was no clinical improvement in his psoriasis. The dose of cyclosporine was increased to the maximum dose of 4 mg/kg/day.
After being on the maximum dose of cyclosporine for one month, the patient returned with persistent psoriasis symptoms and no clinical improvement. Uric acid levels were further elevated, and he now presented with podagra.
Diagnostic review
Cyclosporine was discontinued. Some suggestion of islands of sparing, along with the patient’s history of treatment failures, raised the possibility of alternative diagnoses. A 5-mm punch biopsy was taken to confirm psoriasis and rule out other conditions, including pityriasis rubra pilaris, mycosis fungoides, or other atypical hyperkeratotic dermopathies.
The biopsy was submitted for histological analysis. A dermatopathologist was consulted, and clinical photographs of the affected areas were provided alongside the biopsy specimen.
Histological findings supported the diagnosis of plaque psoriasis.
Why was the patient not given allopurinol to prevent a gout flare when he started cyclosporine and lisinopril?
Before & After Photos
Treatment discussion and outcome
Initial treatment: infliximab
The patient was started on infliximab infusions at an initial dose of 5 mg/kg, administered stat, and repeated at 2 weeks, 6 weeks, and then every 8 weeks. While follow-up visits showed minor improvements, including some thinning of plaques and reduced erythroderma, overall progress was limited, with only a 25% to 30% improvement overall. Despite remaining on infliximab for 10 months, the treatment failed to achieve substantial disease control.
During this period, newer topical treatments, including tapinarof and roflumilast, were also trialed. However, due to the extensive body surface area affected, these therapies were ineffective.
Treatment escalation: risankizumab
After nearly a year, the patient returned with a psoriasis flare following repeated missed follow-ups. At his request, infliximab was increased to 6 mg/kg every 8 weeks. After 2 infusions with little to no improvement, infliximab was discontinued, and risankizumab was initiated using the loading dose protocol. No significant washout period was applied, given the severity of the patient’s disease.
While on risankizumab for 7 months, the patient maintained a BSA of approximately 50% to 60%. However, he was subsequently lost to follow-up for 8 months, during which his psoriasis worsened significantly, with a BSA increasing to 85% to 90% by the time of his return.
Subsequent treatment attempts
The patient was next started on deucravacitinib following appropriate laboratory tests. After 3 months without meaningful improvement, this treatment was discontinued due to lack of efficacy. Acitretin was then trialed for approximately 6 weeks, but the patient’s symptoms worsened. At this point, the patient experienced poor temperature regulation and frequently wore sweaters despite summer heat.
Successful management with bimekizumab
Nearly 3 years after his initial presentation, the patient received his first dose of bimekizumab. He reported a significant reduction in pain severity within 4 hours of the injection, with chronic skin pain decreasing from a 9 to a 3 on a severity scale. At his 4-week follow-up, the patient achieved near-complete clearance, with a BSA of less than 5%. Clinical examination revealed faint pink patches where plaques had resolved, slight xerosis on the lower legs, and a single 1-cm psoriasiform plaque on the right medial elbow.
The patient reported that his psoriasis had not been this well-controlled since his initial diagnosis during adolescence.
Long-term outcomes
Subsequent monthly visits have shown sustained control, with a persistent BSA of 1% to 2%. Notable improvements in both fingernail and toenail health have been observed. After over 20 years of severe, recalcitrant psoriasis, the patient stated that he finally has gained control over his disease. He reports that this significant improvement has been life-changing, offering him relief and stability after decades of debilitating symptoms.