Poster abstracts
At presentation: plaque Ps on the face and scalp, nail Ps, palmo-
plantar feet pustulosis (BSA–4%, PASI –2.1); both pinnas of the
ears were swollen, painful and red; ear lobes were not involved.
The pt suffered from conjunctivitis. The pt had asymmetrical
polyarthritis, dactylitis, achillobursitis. Painful movements at
cervical spine, rotation 30°-35°. ESR 54 mm/h, CRP 99 mg/l,
RF negative, positive HLA B27, HLA B5 not detected. PET-CT
imaging did not reveal any pathological changes besides bilateral
auricular inflammation.
Results: PsA diagnosis was determined according to CASPAR
criteria. RP diagnosis was based on the McAdams criteria. The
diagnosis is definite when no less than three out of six criteria
are present: bilateral auricular chondritis, nonerosive serone-
gative arthritis, nasal septum chondritis, ocular inflammation,
respiratory tract chondritis, and cochlear disorder. Our pt had
bilateral auricular chondritis, conjunctivitis, cochlear disorder.
The diagnosis was confirmed by ear-auricles biopsy which sho-
wed perichondrial inflammation and granulocyte infiltration. The
therapy delivered: methotrexate s/c 10 mg pw; Solu-Medrol i/v
(750 mg cumulatively); methylprednisolone per os 16 mg per day.
Within days, there was normalization of temperature, e ar-auricle
swelling, redness and pain had regressed; hearing was restored,
conjunctivitis passed, the intensity of arthritises, dactylitis and
spondylitis had decreased; the reduction in ESR, CRP was to 14
mm/h, to 7.0 mg/l accordingly.
Conclusion: As is known, when a pt has PsO, he is twice as
likely to develop additional autoimmune diseases. It is of great
importance to properly diagnose and treat cross autoimmune di-
seases. Early diagnosis (within 3 months) and adequate treatment
resulted in rapidly decreased inflammatory process and in escaping
nonreversible changes in cartilage tissues.
P092
SPINY FOLLICULAR HYPERKERATOSIS IN A PSORIA
SIS PATIENT TREATED WITH USTEKINUMAB
Antoanela Carija, Adela Markota Cagalj, Neira Puizina Ivic
University Hospital Centre Split
Introduction: We present a psoriasis patient developing asymp-
tomatic white spiny follicular hyperkeratoses (SFH) after being
treated with ustekinumab for 3 months.
Objectives: This type of eruption has been described under several
names including spiny follicular keratoderma, hyperkeratotic spi-
cules, filiform hyperkeratoses, parakeratotic horns, and follicular
hyperkeratoses (1). Facial hyperkeratotic spicule eruption was re-
ported in association with monoclonal gammopathy. Drug-induced
filiform hyperkeratosis has been reported with cyclosporine, with
BRAF inhibitors (vemurafenib), with acitretin and with vismo-
degib and sorafenib.
Methods: Our patient started ustekinumab treatment in June
2015. At the same time he was treated with metothrexate, folic
acid, metformin and lisinopril/hydrochlorothiazide. Three months
after ustekinumab introduction patient noticed growth of tiny skin
projections located on the face, scalp, upper trunk and upper arms.
Each spiny lesion was approximately 0.5 to 1 mm in diameter and
up to 5 mm high. A biopsy of a white spiny keratotic projection sho-
wed orthokeratosis, achantosis and mild spongiosis in epidermis,
inflammatory infiltrate in chorium and dilatated acrotrichiums.
Condition resolved in several weeks without any treatment and
without ustekinumab cessation.
Results: A similar condition viral-associated trichodysplasia (TS)
was originally described in 1999 as a folliculocentric viral infec-
tion in a patient who was receiving cyclosporine after kidney and
pancreas transplantation. Trichodysplasia spinulosa associated
polyomavirus (TSPyV) was identified in TS lesions and shown
to be the probable cause of this disease (2). Pathogenesis both of
viral-associated TS and BRAF inhibitor-induced SFH is based on
the paradoxical activation of MAPK (mitogen-activated protein
39
kinase) pathway, which regulates a variety of cellular processes
including cell division, differentiation and apoptosis.
Conclusions: Our patient developed SFH possibly due to use of
ustekinumab, IL-12 and IL-23 inhibitor. The latter has a role in
differentiation process of the skin (12), suggesting that inhibition of
IL-23 might explain the imperfect keratinization process observed
in SFH. Considering that in our patient drug was not stopped and
the condition resolved in several weeks without any treatment,
possible cause could be ustekinumab-induced immunosupression
and consequent viral infection.
References:
1. Yanik ME, Erfan G, Albayrak H, et al. Acitretine-induced spiny follicular
hyperkeratosis. Cutan Ocul Toxicol. 2016;35:165-167.
2. DeCrescenzo AJ, Philips EC, Wilkerson MG, et al. Trichodysplasia
spinulosa: A rare complication of immunosuppression. JAAD Case Re-
ports. 2016;2:307-309.
P093
COMBINATION THERAPY OF APREMILAST AND
BIOLOGICAL PRODUCT IN A PATIENT WITH
PSORIASIS
Koji Masuda, Fuminao Kanehisa, Norito Katoh
Department of dermatology, Kyoto Prefectural University of Medicine
Apremilast was approved in March 2017 in Japan for the treat-
ment of psoriasis and psoriatic arthritis. Apremilast appears to
have lower efficacy than biological product. However, its ease
of administration as an oral agent coupled with a mild side ef-
fect profile makes it an attractive option for psoriasis treatment.
While monotherapy with biological products is effective for
many patients with psoriasis, some patients are not satisfied by
the outcome. There are few data or reports about the safety and
efficacy of apremilast in combination of biological product in the
treatment of psoriasis.
We report a 46-year-old man with about a twenty-year history of
plaque psoriasis and psoriatic arthritis who failed several therapies
including topical therapy, phototherapy and etretinate. At the time
of presentation, the patient was using secukinumab for 9 months,
which had controlled his arthritis. However, the patient noted
plaque remained mainly on his lower legs. Apremilast was added
and up-titrated to 30 mg twice per day along with his secukinumab
therapy. After two months of combination therapy, the patient’s
disease has improved and stabilized with only a few scattered
erythematous mildly scaly plaques on his lower legs. The patient
denied side effects of nausea, diarrhea or headache. Laboratory-
work was within normal limits.
However, we also experienced two other cases who failed apre-
milast add on therapy to biological product because of efficacy or
side effects. So, this method may be useful for uncontrolled patient
for psoriasis, more studies are needed to determine the safety and
efficacy of using these drugs together.
P094
PSORIASIS WORST-CASE SCENARIOS: A SERIES OF 3
CASE REPORTS
Elena Popa 1 , Persa Ghitulescu 2 , Patricia Cristodor 1 , Caius So-
lovan 1
Department of Dermatology and Venereology, Clinical Emergency Muni-
cipal Hospital Timisoara; University of Medicine and Pharmacy “Victor
Babes” Timisoara, Romania, 2 Department of Dermatology and Venereo-
logy, Clinical Emergency Municipal Hospital Timisoara
1
Introduction: Psoriasis is a chronic, immune, inflammatory di-
sease, that can occur at any time and it is most common in the age
group 50–69. The reported prevalence of psoriasis in countries
ranges between 0.09% and 11.4%, making psoriasis a serious
global problem.
Objectives: We present a series of 3 case reports that stand for some
of the wo rst-case scenarios a Psoriasis patient could end up in.
Acta Derm Venereol 2018