Update on Erythrodermic Psoriasis: Proposal of a Management Algorithm by an Innovative Severity Evaluation Approach.

Abstract

Erythrodermic psoriasis (EP) is an uncommon and severe form of psoriasis, which exhibits a Th1/Th17/TNF inflammatory pattern. Most patients with EP experience systemic symptoms that necessitate systemic treatments. These treatments include conventional systemic drugs (such as acitretin, cyclosporin A, and methotrexate), biologics (including IL-17, IL-12/23, and TNF-α inhibitors), and small molecule drugs (such as apremilast and JAK inhibitors). Evaluating the severity of EP is critical for determining appropriate treatment strategies. According to an innovative EP severity evaluation approach, patients exhibiting two or more clinical features-fever, exudation, or lymphadenopathy-are classified as having moderate-to-severe EP, while those with one or none of these symptoms are categorized as having mild EP. Mild EP can often be managed with monotherapy using acitretin, methotrexate, or biologics, such as IL-17 or IL-12/23 inhibitors, excluding TNF-α inhibitors. For moderate-to-severe EP, cyclosporine A and biologics, particularly IL-17 or IL-12/23 inhibitors, are recommended. Combination therapies are considered when monotherapies prove ineffective. These may involve combining a biologic with a conventional systemic drug or using two to three conventional systemic drugs together to enhance efficacy. Supportive care plays a critical role in alleviating the discomfort associated with skin lesions and other complications. Additionally, treatments should be tailored to address specific comorbidities, often requiring multidisciplinary collaboration. In our comprehensive review, we summarized the current evidence on therapeutic options for EP, including details on dosages, treatment durations, efficacy, and adverse events. Additionally, we incorporated new evidence on the use of acitretin, biologics, and JAK inhibitors for EP. We also introduced, for the first time, a practical management algorithm based on severity evaluation to guide the appropriate treatment of EP.