Breaking the barrier: oral tacrolimus plus apremilast rescues acute generalized pustular psoriasis with severe comorbidities—a case report

Generalized pustular psoriasis (GPP) is a severe disease. Treatment options for refractory cases with multiple comorbidities remain limited. This report describes a 72-year-old female patient with a 10-year history of plaque psoriasis. The patient experienced recurrent episodes of GPP over the past year, complicated by type 2 diabetes mellitus, hyperlipidemia, hypertension, stage 3 chronic kidney disease (CKD), and pulmonary interstitial fibrosis. Multiple prior therapies had failed, and several conventional medications were contraindicated due to comorbidities. Additionally, the patient refused further treatment with pesolimab. Oral tacrolimus combined with apremilast was administered, resulting in resolution of skin lesions and improvement in renal function.To our knowledge, this is among the first reported cases of successful treatment for recurrent acute GPP, especially refractory acute GPP, using oral tacrolimus in combination with apremilast. The observed therapeutic response suggests potential shared immunological pathways between acute GPP and CKD, which may be influenced by this combination therapy, contributing to improvements in both skin manifestations and renal function. This case provides a valuable reference for optimizing treatment regimens and investigating mechanisms in refractory GPP. Further studies are required to enhance therapeutic efficacy and minimize adverse effects.