Subcutaneous Spesolimab Use in a Patient with Chronic Recurrent Generalized Pustular Psoriasis (GPP)
Case author Saakshi Khattri, MD, presents a case of a 61-year-old Asian female with a 30-year history of GPP who experienced a flare after months of remission following intravenous spesolimab, prompting a transition to subcutaneous maintenance therapy.
By Saakshi Khattri, MD
Case Presentation and Medical History Summary
A 61-year-old Asian female with a 30-year history of generalized pustular psoriasis (GPP) presented with new-onset pustular lesions. Her medical history included hypothyroidism and prediabetes. She had previously been treated with topical corticosteroids, calcineurin inhibitors, oral methotrexate, acitretin, anti–TNF therapy, and an IL-17A inhibitor. In 2022 and 2023, she received intravenous spesolimab for GPP flares, and had remained flare-free since her last infusion in April 2023.
At presentation, she exhibited new lesions on her extremities but denied systemic symptoms. Her Generalized Pustular Psoriasis Physician Global Assessment (GPPPGA) score was 2, consistent with noncoalescent, small pustules and fine scaling.
Physical Exam and Lab Results
At baseline, the patient had erythematous patches with scattered pustules primarily on the arms and legs. She had no systemic symptoms. A complete blood count and comprehensive metabolic panel were unremarkable.
Diagnostic Review
Differential diagnoses included acute generalized exanthematous pustulosis (AGEP), subcorneal pustular dermatosis, and annular pustular psoriasis. However, the patient’s history of chronic GPP and absence of new systemic medication use supported a diagnosis of GPP recurrence.
GPP was confirmed based on clinical examination and disease history. While AGEP typically presents with a more abrupt onset, the patient’s chronic disease course and flare-relapse pattern aligned with GPP.
Before & After Photos
Treatment Decision and Outcome
Recognizing the need for sustained disease control, and in line with the 2024 FDA approval for flare prevention, the patient was transitioned to subcutaneous spesolimab. She received a 600-mg SC loading dose, followed by 300 mg SC every 4 weeks.
At a follow-up visit 6 weeks after initiating therapy, no new active lesions were noted. Existing lesions were resolving, with postinflammatory dyspigmentation. At the 4-month follow-up, the patient had returned to baseline. As of her most recent visit, she maintained clear skin with no signs of relapse and expressed high satisfaction with her care.
Which of the following best explains the rationale for transitioning this patient from intravenous to subcutaneous spesolimab?