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E-IJD® - CORRESPONDENCE
Year : 2021  |  Volume : 66  |  Issue : 2  |  Page : 225
Successful treatment of acrodermatitis continua of hallopeau with an anti-IL-17A agent


Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan

Date of Web Publication16-Apr-2021

Correspondence Address:
Rei Watanabe
Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_584_18

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How to cite this article:
Inoue S, Watanabe R, Ishitsuka Y, Nakamura Y, Fujisawa Y, Okiyama N, Fujimoto M. Successful treatment of acrodermatitis continua of hallopeau with an anti-IL-17A agent. Indian J Dermatol 2021;66:225

How to cite this URL:
Inoue S, Watanabe R, Ishitsuka Y, Nakamura Y, Fujisawa Y, Okiyama N, Fujimoto M. Successful treatment of acrodermatitis continua of hallopeau with an anti-IL-17A agent. Indian J Dermatol [serial online] 2021 [cited 2021 May 6];66:225. Available from: https://www.e-ijd.org/text.asp?2021/66/2/225/313791




Sir,

Acrodermatitis continua of Hallopeau (ACH) is characterized by pustules and atrophic skin changes in the tip of digits, onychodystrophy, and occasional osteolysis. ACH runs a chronic and relapsing course and may evolve into generalized pustular psoriasis (GPP). The disease is often refractory to various treatments and the effectiveness of biologics, such as anti-tumor necrosis factor-α, anti-interleukin (IL)-17A, and anti-IL-12/23 agents, has been reported.[1],[2],[3] However, the reports mentioning the efficacy of biologics are quite limited. We report here a case of ACH who has been treated successfully with anti-IL-17A agent.

A 15-year-old female presented with a 6-month history of severe scaly, erythematous, and pustular eruption on the nails, tip of digits, palms, and soles [Figure 1]a. A biopsy from the heel on histopathology showed hyperkeratosis, parakeratosis, cavities filled with neutrophils in stratum corneum, acanthosis with regular elongation of rete ridges, and lymphohistiocytic infiltrate around the vessels in the upper dermis [Figure 1]b. We emphasized the persistent subungual pustules and made the diagnosis of ACH according to the newly offered diagnostic criteria by European Rare and Severe Psoriasis Expert Network (ERASPEN).[4] Cyclosporine (CyA) in the dose of 3 mg/kg/day brought a dramatic improvement in 2 weeks. However, when the dose of CyA was decreased to 2 mg/kg/day, her disease rapidly worsened. As the increase of the dose of CyA to 3 mg/kg/day for 8 weeks did not improve her disease, we started the treatment with adalimumab. Administration of 80 mg of adalimumab was continued every 2 weeks for 16 weeks resulting in only subtle improvement. The patient was then put on subcutaneous administration of 300 mg secukinumab every 4 weeks and it demonstrated an excellent response in 8 weeks [Figure 1]c. Her disease has been well controlled for 8 months under secukinumab treatment.
Figure 1: (a) Severe scaly, erythematous, and pustular eruption on the nails, tip of digits, and the soles. (b) Hematoxylin–eosin (H–E) staining of the heel showed hyperkeratosis, dyskeratosis, cavities filled with neutrophils in stratum corneum, acanthosis with regular elongation of rete ridges, and lymphohistiocytic infiltrate around the vessels in the upper dermis (top: ×100, bottom: ×200). (c) Dramatic improvement after 8 weeks of secukinumab treatment

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The diagnosis of ACH is in many cases controversial due to the discordance of clinical description among standard dermatology textbooks. The ERASPEN group stated a consensus classification of pustular psoriasis in order to make phenotypically well-matched disease groups for further clinical studies.[4] According to this classification, pustular psoriasis is classified into three groups: GPP, palmoplantar pustulosis, and ACH. A recent study also demonstrated the concurrence of psoriasis vulgaris in 46.2% of ACH based on the diagnostic criteria by the ERASPEN group and still mutations in IL-36 receptor antagonist gene were detected in ACH population.[5] Although our case can also be categorized as palmoplantar psoriasis, considering subungual continuous pustules, we regarded it reasonable to diagnose this case as ACH. Further standardization of diagnosis will help understand the disease pathogenesis.

Involvement of IL-17A in the pathogenesis of pustular psoriasis is well recognized and both innate and adaptive immune cells, such as neutrophils, macrophages, γδT cells, and Th17 cells, are regarded to contribute to IL-17A-enriched condition in the lesion of pustular psoriasis. Even with the dominance of IL-17A, however, the efficacy of anti-IL-17A agents on pustular psoriasis, especially ACH, is not established firmly. Anti-IL-17A agents can be good candidates for the treatment of ACH and further reports will be awaited.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Hoegler KM, John AM, Handler MZ, Schwartz RA. Generalized pustular psoriasis: A review and update on treatment. J Eur Acad Dermatol Venereol 2018;10:1645-51.  Back to cited text no. 1
    
2.
Sehgal VN, Verma P, Sharma S, Srivastava G, Aggarwal AK, Rasool F, et al. Acrodermatitis continua of Hallopeau: Evolution of treatment options. Int J Dermatol 2011;50:1195-211.  Back to cited text no. 2
    
3.
Saunier J, Debarbieux S, Jullien D, Garnier L, Dalle S, Thomas L. Acrodermatitis continua of Hallopeau treated successfully with ustekinumab and acitretin after failure of tumour necrosis factor blockade and anakinra. Dermatology 2015;230:97-100.  Back to cited text no. 3
    
4.
Navarini AA, Burden AD, Capon F, Mrowietz U, Puig L, Koks S, et al. European consensus statement on phenotypes of pustular psoriasis. J Eur Acad Dermatol Venereol 2017;31:1792-9.  Back to cited text no. 4
    
5.
Twelves S, Mostafa A, Dand N, Burri E, Farkas K, Wilson R, et al. Clinical and genetic differences between pustular psoriasis subtypes. J Allergy Clin Immunol 2018;143:1021-6.  Back to cited text no. 5
    


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