記住我
Sir,
Acrodermatitis continua of Hallopeau (ACH) is a chronic, destructive pustulosis involving one or more hands and feet. It is generally regarded as a rare variant of pustular psoriasis, lacking established therapeutic recommendations.[1] Chronic inflammation can lead to sclerosis and osteolysis, as well as onychodystrophy and anonychia. Inverse psoriasis (IP), also known as intertriginous psoriasis, is considered a special site of involvement of plaque psoriasis, characterized by the sensitivity of the afflicted skin.[2] Although it is not clear if ACH is related to IP, psoriatic lesions in these particular localizations such as the face, scalp, and intertriginous or palmoplantar areas have a lot in common. Patients often feel humiliated and have a considerably lower quality of life. Additionally, lesions in these regions need special consideration since they frequently respond poorly to conventional methods. Ixekizumab, an interleukin (IL)-17 blockade, has demonstrated effectiveness in the treatment of genital and generalized pustular psoriasis.[3]
Here we report a case of a 28-year-old male patient with an 8-year history of IP who presented progressive dystrophic lesions on most fingernails for 2 years. He had well-circumscribed, macerated, shiny erythematous plaques involving inguinal folds and axillae [Figure 1]a. Physical examination also showed distinct pustules and nail destruction on most distal digits as well as erythema and desquamation of periungual skin [Figure 2]a. A bacterial or fungal infection was ruled out by microbiological examination. Biopsy results were consistent with the diagnosis of IP and ACH. His previous treatment included acitretin and etanercept, with no satisfactory benefits. We then began ixekizumab monotherapy in the recommended dose for plaque psoriasis (initial dose of 160 mg followed by 80 mg every 2 weeks from Week 2 through Week 12, and thereafter 80 mg every 4 weeks). 8 weeks after the first injection, the inguinal folds and axillae lesions cleared up entirely [Figure 1]b. Pustules and nail destruction gradually decreased and markedly resolved by week 24 [Figure 2]b. After 32 weeks, ACH was completely healed, and interestingly, longitudinal melanonychia [Figure 2]c confirmed by dermatoscopy arose on all the previously affected ACH fingernails. The patient did not encounter any adverse event or recurrence of lesions until now (Week 76).
Figure: 1: IP before and after the ixekizumab monotherapy. Change of lesions of the right axilla at (a) baseline and (b) week 8. IP = Inverse Psoriasis
Figure 2: ACH before and after the ixekizumab monotherapy. Change of lesions of the right hand at (a) baseline, (b) week 24 and (c) week 32. ACH = Acrodermatitis continua of HallopeauIxekizumab has been recommended for patients with moderate-to-severe psoriasis plus genital involvement[4] (a considered part of IP presentation).[2] Ixekizumab is also the only drug that contains data on genital psoriasis on the Food and Drug Administration (FDA) label.[5] In a randomized, placebo-controlled, phase III clinical trial (IXORA-Q) associated with moderate-to-severe genital psoriasis, ixekizumab significantly improved the appearance of genital lesions, pruritus, sexual health, and quality of life during 12 weeks.[5],[6] The IXORA-Q trial also demonstrated the long-term efficacy and safety of ixekizumab for up to 52 weeks.[7] For ACH, its pathogenesis may be associated with mutations in IL36RN, which may result in the malfunction of the IL-36R antagonist and cause the synthesis of IL-17.[1] There have been cases of ACH treated with ixekizumab.[8],[9],[10] In our patient, ixekizumab enabled a quick remission of both IP and ACH, and achieved satisfying long-term outcomes. The longitudinal melanonychia revealed inflammation triggered activation of melanocytes, and not due to the drug because only psoriatic nails showed this change. In conclusion, our case further confirms ixekizumab is a potential treatment option for patients with difficult-to-treat ACH or IP and the long-term efficacy and safety of this treatment need further observation.
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.
Acknowledgment
The patient in this manuscript has given written informed consent to the publication of his case details. This work was supported by the National Natural Science Foundation of China (82073439).
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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