Study Confirms Recommendation of Infliximab for Pustular Psoriasis of Pregnancy

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New research aligns with the US recommendation of infliximab as a first-line treatment of pustular psoriasis of pregnancy, with findings highlighting both the efficacy of tumor necrosis factor-alpha (TNF-α) inhibitors and that early biologic intervention during pregnancy can lead to rapid remission of refractory pustular psoriasis.¹

These conclusions were the results of research led by YuFei Wang, BM, from the department of dermatology at the First Affiliated Hospital of Nanjing Medical University in Nanjing, China. Wang et al. noted that generalized pustular psoriasis of pregnancy is a form of generalized pustular psoriasis and can be triggered by pregnancy, leading to adverse or fatal neonatal outcomes potentially.²

“Appropriate treatment is essential for managing patients with (generalized pustular psoriasis of pregnancy),” Wang and colleagues wrote. “Biologic treatment has become a significant treatment option for (generalized pustular psoriasis of pregnancy), and this review summarized treatment outcomes of biologic therapies for (generalized pustular psoriasis of pregnancy).”¹

Study Design

In March 2024, the research team carried out a search of the Embase and MEDLINE databases. The team identified 104 studies in total, though only 25 of these met their predetermined criteria for inclusion in their analysis.

Data on 27 study subjects were assessed, with these participants having received 29 biologic therapies and had an average age of 27.7 years. These subjects also had a mean gestational age of 22.5 weeks, with 74.1% of them reporting a history of generalized pustular psoriasis or psoriasis vulgaris.

When the research team looked at biologic exposure during the pregnancy period, they showed that 51.7% of cases involved administration during pregnancy. They also reported that 48.3% had been administered in the postpartum period.

The investigators concluded that 51.9% had been treated using biologic therapies alongside systemic options, adding that biologics were categorized into 3 groups: IL-17 inhibitors (34.5%, 10 of 29 therapies), TNF-α inhibitors (55.2%, 16 of 29), and IL-12/23 inhibitors (10.3%, 3 of 29). They noted that 29.6% of the 27 participants were found to have a mutation in their IL36RN gene.

Treatment Comparisons

IL-17 inhibition led to an 80% complete resolution rate and a 20% partial resolution rate, with the research team reporting an average complete resolution time of 3.7 weeks. The results of IL-12/23 inhibition showed that, despite their less frequent utilization, they would lead to complete resolution in 66.7% of cases and partially resolve among 33.3%, with the average complete resolution time noted as 19.5 weeks.

Another notable finding was that TNF-α inhibitors, reported to be the most frequently implemented by patients, led to complete resolution among 50% of the 16 users and partial resolution among the other 50%. Using TNF-α inhibitors, the average time to complete resolution was found to be 6.8 weeks.

TNF-α inhibitors during pregnancy led to a higher rate of complete resolution, with 85.7% specifically, and no cases of psoriasis recurrence. This contrasted with a rate of only 22.2% complete resolution and a 22.2% rate of recurrence in post-delivery administration. The team did note that no adverse events were seen in such cases.

What These Findings Suggest

The investigators noted that these data align with current guidelines in the US suggesting first-line treatment with TNF-α inhibitor infliximab for pustular psoriasis of pregnancy. Only a single reported case was shown to have led to infliximab-induced IgA nephropathy.

The aforementioned findings also showed that IL-17 inhibition was most effective against the skin condition, with the research team suggesting that no major adverse effects had been observed in either pregnant women or their fetuses.

“Limitations include a lack of evidence from randomized controlled trials and small sample sizes, and most follow-ups were not long enough to identify potential threats to newborns,” they wrote.

References

1. ^{Wang, Y., Zhou, C., Hou, Y., Gao, Y., Lu, J. and Yin, Z. (2024), Biologic treatment outcomes in generalized pustular psoriasis of pregnancy: A systematic review. Australas J Dermatol. https://doi.org/10.1111/ajd.14357.}
2. ^{Seishima M, Fujii K, Mizutani Y. Generalized pustular psoriasis in pregnancy: current and future treatments. Am J Clin Dermatol. 2022; 23(5): 661–671.}