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A patient with medication-induced severe acute generalized exanthematous pustulosis responded to treatment with secukinumab after unsuccessful courses of topical and systemic steroids.
Acute generalized exanthematous pustulosis (AGEP) is typically treated with a systemic corticosteroid and clears quickly, but other systemic therapies are sometimes necessary in severe or persistent cases. A case study published in Frontiers in Medicine reported that secukinumab could be a potential therapeutic option for stubborn cases of AGEP.
AGEP is usually a drug-related condition and is severe, with rapid onset of skin redness accompanied by small non-follicular pustules. In this case, a 41-year-old male patient with a history of psoriasis developed confirmed AGEP that appeared 1 day after treatment with a quadruple antituberculosis drug.
“Prior to clinical admission to our department, the patient was misdiagnosed as active tuberculosis and was sequentially prescribed isoniazid, rifampicin, ethambutol, and pyrazinamide in lazaretto,” the authors wrote. “At admission, active tuberculosis was excluded based on clinical symptoms and results of repeated chest computed tomography. We confirmed that the patient only had latent tuberculosis infection.”
He presented with widespread redness, pustules, lesions, and a fever. Further tests and examination showed a high white blood cell count and C-reactive protein, subcorneal pustules, spongiosis, and lymphocyte and eosinophils infiltration in the skin. Approximately 80% of his body surface area was affected, with pinpoint pustules and erythema multiforme-like lesions diffusely spread over the upper arms and palms.
Topical and systemic corticosteroids were ineffective after 4 days of treatment, but secukinumab therapy — typically used to manage moderate to severe plaque psoriasis and psoriatic arthritis — led to remission and was safe without increased infection risk. The patient received 300mg of secukinumab, after which pustules faded and fever decreased at day 3.
The patient was treated with secukinumab for 1 month, and subsequent follow-ups for 2 years showed no changes in lung pathology. Overall, the study authors suggested secukinumab warrants more research as a possible treatment for AGEP.
“The underlying mechanism of action of secukinumab on AGEP is related to interleukin (IL)-17,” they wrote. “AGEP has been classified as a T cell-related sterile neutrophilic inflammatory response with a predominant T-helper (Th) 1 cell and Th17. Th17 cells release IL-17, which affects neutrophil recruitment. Therefore, the IL-17 pathway is a potential therapeutic target shown to be implicated in AGEP.”
While secukinumab therapy holds promise in treating AGEP, more research is needed to confirm its safety and effectiveness in this disease setting.
Zhang L, Xu Q, Lin T, et al. Case report: successful treatment of acute generalized exanthematous pustulosis with secukinumab. Front Med (Lausanne). Published online December 16, 2021. doi:10.3389/fmed.2021.758354