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Clinical Practice Article
Revised

Case report: Treating a co-existence of hidradenitis suppurativa and psoriasis with different therapeutic approaches

[version 2; peer review: 3 approved]
Previously titled: Case report: Treating a combination of hidradenitis suppurativa and psoriasis with different therapeutic approaches
PUBLISHED 22 Dec 2020
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Abstract

Hidradenitis suppurativa and psoriasis are considered chronic inflammatory diseases suggesting the existence of common pathogenetic pathways. We present two cases of comorbid psoriasis and hidradenitis suppurativa, treated with certolizumab pegol and brodalumab due to failure of response to other conventional therapies. Monoclonal antibody therapies have revolutionized the treatment of chronic inflammatory disorders such as psoriasis and hidradenitis suppurativa. Given the good clinical response to anti-IL-17 and anti-tumor necrosis factor agents in patients undergoing psoriasis and hidradenitis treatment, investigations on this direction could represent the starting point in new therapeutic approach for revolutionary treatment in these difficult-to-treat diseases.

Keywords

hidradenitis suppurativa, psoriasis, certolizumab, brodalumab

Revised Amendments from Version 1

In the revised version of our manuscript, we changed the title to “Treating co-existence of hidradenitis suppurativa and psoriasis”, instead of the term combination. 
Also, we provide severity assessment before and after treatment for psoriasis and hidradenitis, for both cases. The clinical improvement is estimated using the PASI (Psoriasis Area Severity Index) score, BSA (Body Surface Area), and IHS4 (International Hidradenitis Suppurativa Severity Scoring System) score, while the impact on the quality of life is estimated with the DLQI (Dermatology Life Quality Index) score.

See the authors' detailed response to the review by Georgios Nikolakis
See the authors' detailed response to the review by Thrasyvoulos Tzellos
See the authors' detailed response to the review by Kevin K. Wu

Introduction

Hidradenitis suppurativa (HS) and psoriasis are considered chronic inflammatory diseases suggesting the existence of common pathogenetic links13. Patients with psoriasis and HS have elevated levels of tumor necrosis factor (TNF) and interleukin-17 (IL-17) in lesional and non lesional tissues, which has been the justification for selective targeting of these inflammatory pathways47. We present two cases of co-existence of psoriasis and HS treated with certolizumab pegol and brodalumab due to the peculiarities of treatment with other therapies.

Case report

The first patient, a 27-year-old Caucasian woman, presented with extensive psoriasis vulgaris covering her head, trunk, lower limbs over a period of 5 years, with a recent PASI (Psoriasis Area Severity Index) score of 10.5 and 10% BSA (Body Surface Area) score. She, also, suffered from psoriatic arthritis with axial joint involvement (manifestations of hierolagonitis) over the previous 2 years and moderate HS of Hurley II stage disease on the axillae over the last year, with IHS4 (International Hidradenitis Suppurativa Severity Scoring System) score 10 (Figure 1a, b, c, d, e). Despite the limited extent of the lesions, the patient presented considerable pain, discomfort and substantial negative effect on quality of life. Patient’s DLQI (Dermatology Life Quality Index) score was, also very high, 21. The patient didn’t have a positive family history for the above diseases and the molecular control for HLA-B27 was negative. Previous treatments with topical corticosteroids and methotrexate for one year were not effective and treatment with apremilast for 8 months didn’t offer clinical improvement in both diseases. The patient underwent comprehensive laboratory investigations, including complete blood cell count, chemistry panel, tuberculosis (Quantiferon-TB Gold test), human immunodeficiency virus and hepatitis B and C screening and chest x-ray. Since all these examinations revealed values within normal limits and because of the patient’s desire for childbirth, she was treated with certolizumab pegol (CZP). The initial dose was 400mg, followed by 400mg every 2 weeks. Treatment with CZP significantly improved psoriasis and psoriatic arthritis at week 8 and HS at week 12. The PASI score after treatment was 1, BSA was 2%, whereas IHS4 score was 1. Except the clinical improvement, the DLQI score was impressively reduced to 2. (Figure 1f–i). She continues treatment 9 months after and at 3 months follow-up is fully controlled.

eab2b1a0-d335-4b9a-92a0-7a9d510d466a_figure1.gif

Figure 1. Psoriatic and HS lesions of patient 1.

(ae) Psoriatic and HS lesions of first patient before treatment with certolizumab pegol. (fj) Psoriatic and HS lesions of first patient after treatment with certolizumab pegol.

The second patient, a 42-year-old Caucasian man, was referred to our hospital’s dermatological department with multiple, itchy, scaly, red-gray psoriatic plaques covering almost all his body: scalp, arms, trunk, thighs (Figure 2a–d) for the previous 6 months, over a history of 10 years psoriatic disease (recent PASI: 18.5, BSA: 45%). The patient, also, experienced concomitant psoriatic arthritis with peripheral joint involvement and dactylitis discomfort over the previous 10 years, and moderate HS of Hurley II stage disease appearing on the groin area in the previous year. The IHS4 score was 10. The above diseases had a negative impact factor on his quality of life with DLQI 25. The patient’s family history was positive: his mother and sister were also suffering from psoriasis. The patient had until recently received almost all the available therapies related to his diseases: cyclosporine for 2 years interrupted due to urea and creatinin increase (examinations restored after discontinuation), methotrexate and golimumab for 3 years with improvement only in psoriatic arthritis, adalimumab ustekinumab and secukinumab, with a partial response. After a complete laboratory examination, with results in normal limits, the patient started therapy with brodalumab. The initial dose was 210 mg at weeks 0, 1, 2 followed by 210 mg every 2 weeks. His psoriasis and psoriatic arthritis were highly improved at week 8 (Figure 2 e–h), as was HS at week 16. The PASI score after treatment was 1.5, the BSA was 8%, while IHS4 score was reduced to 3. He has continued treatment for 1 year; at 3 months follow-up he reported improvement in his quality of life and the DLQI score was 1.

eab2b1a0-d335-4b9a-92a0-7a9d510d466a_figure2.gif

Figure 2. Psoriatic lesions of patient 2.

(ad) Psoriatic lesions of second patient before treatment with brodalumab. (eh) Psoriatic lesions of second patient after treatment with brodalumab.

Discussion

Monoclonal antibody therapies have revolutionized the treatment of chronic inflammatory disorders such as psoriasis and HS. CZP is a TNF inhibitor that does not have a fragment crystallizable (Fc) region, which is normally present in a complete antibody and therefore it does not cause antibody-dependent cell-mediated cytotoxicity810. In contrast to other whole-antibody anti-TNFs, CZP crosses the placenta only by passive diffusion and could therefore be considered as the first-line choice of treatment for women who wish to become pregnant. Since CZP is an anti-TNF drug, therapies which have good clinical response in both psoriasis/psoriatic arthritis and HS, it was chosen as the treatment of choice in our case since it also has a safe profile for possible future pregnancy.

Brodalumab is a monoclonal antibody against human IL-17 receptor A (IL-17RA). Given its efficacy in psoriasis and its mechanism of action in psoriatic arthritis and HS, due to the patient’s non response to all the available treatment options it was decided its use on the above combination diseases1114.

It is well known that psoriasis and HS likely share immunopathogenetic pathways, including involvement of IL-17 and TNF. Given the good clinical response to anti-IL 17 and anti-TNF drugs in psoriasis and HS treatment, investigations into this direction could represent a starting point for a new therapeutic approach for revolutionary treatment of two difficult to treat diseases.

Data availability

All data underlying the results are available as part of the article and no additional source data are required.

Consent

Written informed consent for publication of their clinical details and clinical images was obtained from the patients.

Comments on this article Comments (1)

Version 2
VERSION 2 PUBLISHED 22 Dec 2020
Revised
Version 1
VERSION 1 PUBLISHED 26 Nov 2019
Discussion is closed on this version, please comment on the latest version above.
  • Reader Comment 17 Dec 2019
    Michael Schön, University Medical Center Göttingen, Germany, Göttingen, Germany
    17 Dec 2019
    Reader Comment
    In recent years, experimental and clinical evidence has accumulated that certain pathophysiological relationships exist between acne inversa and psoriasis. Therefore, it seems logical to treat the two diseases with a ... Continue reading
  • Discussion is closed on this version, please comment on the latest version above.
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how to cite this article
Tampouratzi E, Kanni T, Katsantonis J and Douvali T. Case report: Treating a co-existence of hidradenitis suppurativa and psoriasis with different therapeutic approaches [version 2; peer review: 3 approved]. F1000Research 2020, 8:2002 (https://doi.org/10.12688/f1000research.21216.2)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 2
VERSION 2
PUBLISHED 22 Dec 2020
Revised
Views
3
Cite
Reviewer Report 08 Jan 2021
Kevin K. Wu, University of California, Irvine, Irvine, CA, USA 
Approved
VIEWS 3
Accept. No ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Wu KK. Reviewer Report For: Case report: Treating a co-existence of hidradenitis suppurativa and psoriasis with different therapeutic approaches [version 2; peer review: 3 approved]. F1000Research 2020, 8:2002 (https://doi.org/10.5256/f1000research.30681.r76345)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Views
6
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Reviewer Report 07 Jan 2021
Georgios Nikolakis, Department of Dermatology, Venereology, Allergology and Immunology, Dessau Medical Center, Brandenburg Medical School Theodor Fontane, Dessau, Germany;  European Hidradenitis Suppurativa Foundation, Dessau, Germany 
Approved
VIEWS 6
In this version of the manuscript Tampouratzi and colleagues have provided all validated scores and patient reported outcomes ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Nikolakis G. Reviewer Report For: Case report: Treating a co-existence of hidradenitis suppurativa and psoriasis with different therapeutic approaches [version 2; peer review: 3 approved]. F1000Research 2020, 8:2002 (https://doi.org/10.5256/f1000research.30681.r76343)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Version 1
VERSION 1
PUBLISHED 26 Nov 2019
Views
16
Cite
Reviewer Report 28 Sep 2020
Kevin K. Wu, University of California, Irvine, Irvine, CA, USA 
Approved with Reservations
VIEWS 16
Thank you for these two interesting cases. One major thing missing from this paper are objective measurements of improvement after starting the respective therapies. Simply stating "His psoriasis and psoriatic arthritis were highly improved at week 8 (Figure 2 e–h), ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Wu KK. Reviewer Report For: Case report: Treating a co-existence of hidradenitis suppurativa and psoriasis with different therapeutic approaches [version 2; peer review: 3 approved]. F1000Research 2020, 8:2002 (https://doi.org/10.5256/f1000research.23356.r71707)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 22 Dec 2020
    Theodora Kanni, Andreas Sygros University Hospital, Athens, 161 21, Greece
    22 Dec 2020
    Author Response
    Dear Dr. Wu,
    We revised our manuscript according to your comments.
    We provide severity assessment before and after treatment for both cases.
    The clinical improvement for psoriasis and hidradenitis is ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 22 Dec 2020
    Theodora Kanni, Andreas Sygros University Hospital, Athens, 161 21, Greece
    22 Dec 2020
    Author Response
    Dear Dr. Wu,
    We revised our manuscript according to your comments.
    We provide severity assessment before and after treatment for both cases.
    The clinical improvement for psoriasis and hidradenitis is ... Continue reading
Views
26
Cite
Reviewer Report 11 Dec 2019
Georgios Nikolakis, Department of Dermatology, Venereology, Allergology and Immunology, Dessau Medical Center, Brandenburg Medical School Theodor Fontane, Dessau, Germany;  European Hidradenitis Suppurativa Foundation, Dessau, Germany 
Not Approved
VIEWS 26
I have prepared a PDF file with most of the points I think need to be addressed in order to make this case acceptable for indexing - please find the file hereFor the second case we have really no proof, ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Nikolakis G. Reviewer Report For: Case report: Treating a co-existence of hidradenitis suppurativa and psoriasis with different therapeutic approaches [version 2; peer review: 3 approved]. F1000Research 2020, 8:2002 (https://doi.org/10.5256/f1000research.23356.r57162)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 22 Dec 2020
    Theodora Kanni, Andreas Sygros University Hospital, Athens, 161 21, Greece
    22 Dec 2020
    Author Response
    Dear Dr. Nikolakis,
    We revised our manuscript according to your comments.
    We provide severity assessment before and after treatment for both cases.
    The clinical improvement for psoriasis and hidradenitis is ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 22 Dec 2020
    Theodora Kanni, Andreas Sygros University Hospital, Athens, 161 21, Greece
    22 Dec 2020
    Author Response
    Dear Dr. Nikolakis,
    We revised our manuscript according to your comments.
    We provide severity assessment before and after treatment for both cases.
    The clinical improvement for psoriasis and hidradenitis is ... Continue reading
Views
15
Cite
Reviewer Report 10 Dec 2019
Thrasyvoulos Tzellos, Department of Clinical Medicine, University of Tromsø, Tromsø, Norway 
Approved
VIEWS 15
I suggest changing the title to:
"Treating co-existence of hidradenitis suppurativa and psoriasis"

Introduction:
  • Please change "We present two cases of comorbidity of psoriasis and HS” to ”We present two cases of
... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Tzellos T. Reviewer Report For: Case report: Treating a co-existence of hidradenitis suppurativa and psoriasis with different therapeutic approaches [version 2; peer review: 3 approved]. F1000Research 2020, 8:2002 (https://doi.org/10.5256/f1000research.23356.r57163)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 22 Dec 2020
    Theodora Kanni, Andreas Sygros University Hospital, Athens, 161 21, Greece
    22 Dec 2020
    Author Response
    Dear Prof. Tzellos,

    We revised our manuscript according to your comments. All your comments were taken into account and please find below the answers:
    • We changed the
    ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 22 Dec 2020
    Theodora Kanni, Andreas Sygros University Hospital, Athens, 161 21, Greece
    22 Dec 2020
    Author Response
    Dear Prof. Tzellos,

    We revised our manuscript according to your comments. All your comments were taken into account and please find below the answers:
    • We changed the
    ... Continue reading

Comments on this article Comments (1)

Version 2
VERSION 2 PUBLISHED 22 Dec 2020
Revised
Version 1
VERSION 1 PUBLISHED 26 Nov 2019
Discussion is closed on this version, please comment on the latest version above.
  • Reader Comment 17 Dec 2019
    Michael Schön, University Medical Center Göttingen, Germany, Göttingen, Germany
    17 Dec 2019
    Reader Comment
    In recent years, experimental and clinical evidence has accumulated that certain pathophysiological relationships exist between acne inversa and psoriasis. Therefore, it seems logical to treat the two diseases with a ... Continue reading
  • Discussion is closed on this version, please comment on the latest version above.
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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