Efficacy and Safety of Injection Secukinumab in Patients of Pediatric Erythrodermic Psoriasis

Dear Editor, Psoriasis is a chronic, immune-mediated inflammatory skin disease affecting approximately 125 million people.[1] The prevalence of EP is 1–2%.[2] Erythrodermic psoriasis (EP) in children, a dermatological emergency, is very rare and often considered a refractory variant of psoriasis with high morbidity and mortality. Conventional treatments are effective but have a variable side effect profile. Biologics, such as secukinumab, have proven effective in treating plaque psoriasis. However, real-world studies on secukinumab use in treating EP in the pediatric population are scarce. This is a series of eight pediatric patients aged 9 to 15 years (five males and three females) who presented to the dermatology outpatient department with erythema and scaling involving more than 90% of body surface area (BSA). The lesions in all cases typically began as multiple erythematous papules that gradually increased in size and number, eventually coalescing to involve the entire body, accompanied by large silvery-white scales. Each patient had a history of chronic plaque psoriasis for a variable duration ranging from six months to one year. There was a history of application of topical steroids (mometasone furoate 0.1% cream) for a variable duration. A detailed history of potential triggering factors for erythroderma was taken. Each patient had been treated previously with conventional treatments for six to eight months; however, patients showed minimal response, with recurrent flare-ups leading to disease progression. Cutaneous findings included widespread erythema and desquamation involving the entire body surface [Figures 1a and 2a]. Given the refractory nature of the disease and the suboptimal response to conventional treatment previously, targeted biologic therapy with secukinumab was planned (150 mg of secukinumab was given subcutaneously at weeks 0, 1, 2, 3, and 4 i.e, five doses, and then the next five doses were given at monthly intervals). All routine investigations, including cardiological and tubercular workup were done. Prior to initiation of secukinumab therapy, an assessment including baseline evaluation of Psoriasis Area and Severity Index (PASI), Children Dermatology Life Quality Index (CDLQI) scores, and Investigator Global Assessment score (IGA) was done. After stopping the active treatment, patients were followed up for three months to evaluate therapeutic efficacy, disease recurrence, and incidence of adverse effects.Figure 1: (a) Diffuse erythema with scaling present on the body at baseline. (b) Subsidence of erythema and scaling at 24th week after therapy, with a few areas showing post-inflammatory hyperpigmentationFigure 2: (a) Diffuse erythema with surface showing large silvery white scales present on the body, (b) Complete subsidence of erythema and scaling at 24th weekAll of them showed significant clinical improvement, as evidenced by reductions in PASI, CDLQI, and IGA scores. The primary outcome was assessed by PASI. By week-4, six out of eight patients achieved PASI 90, while the remaining two patients reached PASI 90 by week 8. Thus, at the end of 8 weeks, all patients (100%) had achieved PASI 90. Complete disease clearance (PASI 100) was observed in seven patients by week 12, with all patients (100%) achieving PASI 100 by week 16 [Table 1, Figures 1b and 2b]. The absolute reduction in mean PASI is 30.2±7.89 with p value <0.001 which is statistically significant. Baseline CDLQI scores ranged from 11 to 21 [Table 1]. By week 24, CDLQI scores reduced significantly, ranging from 0 to 3, indicating substantial improvement in quality of life. The IGA scores also demonstrated a significant reduction by the end of the 24-week treatment period.Table 1: Clinicodemographic character of studied patientsOn assessing the adverse effects, only two patients had mild pain and a burning sensation at the injection site. Two patients experienced transient sore throat and nasal congestion after the first four injections; however, these symptoms were self-limiting , and disappeared within two- three days. No severe adverse life-threatening complications were observed throughout the treatment period. No patient experienced a relapse of erythroderma during the three months post-treatment follow-up period. Erythrodermic psoriasis is a severe inflammatory skin disorder that may arise from psoriasis vulgaris or pustular psoriasis due to systemic complications, infections, or medications. Psoriasis pathogenesis is driven by T-helper 17 (Th17) cells, which produce interleukin-17 (IL-17), a key cytokine promoting inflammation and keratinocyte proliferation. Secukinumab, a fully humanized monoclonal antibody, selectively inhibits IL-17A, thereby disrupting the inflammatory cascade. In our study, all patients achieved PASI-100 by 16 weeks, highlighting the high effectiveness of secukinumab in pediatric erythrodermic psoriasis. Our findings are consistent with those reported by Mateu-Puchades et al.,[3] who conducted a study on adult patients with psoriatic erythroderma and demonstrated a significant reduction in PASI 90 and improvement in DLQI at 16 weeks. In an Indian retrospective study conducted by Neema et al.,[4] 75% of patients achieved PASI 75 within four weeks of treatment with secukinumab, further supporting its rapid onset of action in erythrodermic psoriasis. A case, documented by Dogra et al.,[5] involved a 13-year-old male diagnosed with psoriasis at the age of six years, who later developed erythroderma at the age of nine years. The patient had an inadequate response to conventional therapies for three years before being initiated on secukinumab, which resulted in complete disease clearance (PASI 100) without any adverse effects. This case series suggests that secukinumab can be a viable therapeutic option for pediatric erythrodermic psoriasis; however, larger controlled studies are required to establish its long-term efficacy and safety in this population. Authors’ contributions We confirm that all authors have read and approved the manuscript for submission. All authors meet authorship criteria, and the manuscript represents honest work. Declaration of patient consent The authors certify that they have obtained all appropriate parent consent forms. In the form, the parents given their consent for their wards’ images and other clinical information to be reported in the journal. The parents understand that their wards’ 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. Use of artificial intelligence (AI) The preparation of this manuscript was carried out entirely by the author without the use of artificial intelligence technologies.