Biologic Agents Are More Effective, Have Higher Drug Survival for Generalized Pustular Psoriasis

Pustular psoriasis
Pustular psoriasis
Patient and disease characteristics and drug survival rates of treatment in patients with generalized pustular psoriasis (GPP) were assessed.

Biologic agents were more effective than nonbiologic therapies with higher drug survival in the treatment of generalized pustular psoriasis (GPP), according to study findings published in Dermatologic Therapy.

In this study, researchers retrospectively analyzed 201 treatment series in 86 patients with GPP who were treated at 5 university medical centers. The mean onset of disease in the overall population was at 51.2 years of age with a corresponding mean disease duration of 8.7 years.

Treatments administered to these patients included methotrexate (n=42), acitretin (n=28), fumaric acid esters (n=19), etanercept (n=18), infliximab (n=18), adalimumab (n=17), cyclosporine (n=17), secukinumab (n=14), ustekinumab (n=14), ixekizumab (n=7), guselkumab (n=5), and apremilast (n=2).

An excellent overall treatment response was achieved in 41.3% of all treatment courses. In addition, partial response was achieved in 31.4% and a nonresponse was observed in 27.3% of all treatment courses. Treatment with biologic agents was significantly more effective than treatment with nonbiological agents in terms of the excellent response rates (47.4% vs 35.9%, respectively; P =.02).

The overall median drug survival was 14.0 months, with a significantly higher median drug survival rate found in the patients treated with biologic therapies (36.0 vs 6.0 months; P <.001).

Crude probabilities of survival were highest for secukinumab (hazard ratio [HR] of drug discontinuation compared with acitretin, 0.22; P =.02), followed by ixekizumab (HR, 0.38; P =.38), ustekinumab (HR, 0.38; P =.07), adalimumab (HR, 0.59; P =.23), etanercept (HR, 0.62; P =.23), infliximab (HR, 0.69; P =.38), cyclosporine (HR, 1.00; P =.99), acitretin (reference for HR), fumaric acid esters (HR, 1.06; P =.89), methotrexate (HR, 1.26; P =.51), and apremilast (HR, 3.44; P =.11).

In an analysis adjusted for age, gender, psoriatic arthritis, and number of prior systemic antipsoriatic treatments, the rate of drug discontinuation was significantly lower in patients with 1 prior therapy vs patients with 2 or more previous therapies (HR, 0.44; P =.01).

Limitations of this study included its retrospective design as well as the small number of patients in the overall cohort.

Based on their evidence, the investigators of this study recommend “starting with acitretin as first-line therapy, escalating to cyclosporine for short-term control or methotrexate, followed by biologicals, particularly IL-17/IL-17R antagonists, IL-(12)/23 inhibitors, or TNF-α blockers, as second-line treatment or first-line in severely affected patients.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Kromer C, Loewe E, Schaarschmidt ML, et al. Drug survival in the treatment of generalized pustular psoriasis: A retrospective multicenter study. Published online January 26, 2021. Dermatol Ther. doi:10.1111/dth.14814