Stopping a psoriasis biologic: who is at risk of a pustular flare

The edition in brief

Today's dermatology edition ends on stopping biologics in plaque psoriasis. A multicentre cohort in JAAD (25 September) found a distinct pustular flare — painful, diffuse erythema with pustules and swelling, mostly on the legs — after 86 of 1,198 biologic withdrawals (7.2%). It was associated with a family history of psoriasis, psoriatic arthritis, a previous flare of this type, repeated withdrawal–relapse cycles and slow early response; the design was observational. One-year results from two phase 3 trials of icotrokinra, an oral peptide blocking the IL-23 receptor, in 1,505 adults showed about 70–75% clear or almost clear from week 24 to week 52, and 85–90% of week-16 responders kept their response. A phase 2 trial of ruxolitinib 1.5% cream in 64 adults with cutaneous lichen planus found treatment success in 50.0% vs 21.9% with vehicle at 16 weeks, with similar gains in itch. In the OptIMMize-1 phase 3 study of 137 children, risankizumab gave similar PASI 75 rates to ustekinumab at week 16 but more complete clearance (PASI 100 40.7% vs 17.9%). The pearl is avoiding systemic corticosteroids in psoriasis.