Temporal trends and real-world effectiveness of biologic therapies in generalized pustular psoriasis: a 7-year retrospective cohort study

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Introduction Generalized pustular psoriasis (GPP) is a severe, life-threatening disease with a particularly high burden in Asian populations. However, real-world evidence on the effectiveness of biologic therapies remains limited, especially in resource-limited settings.Objectives To describe the clinical profiles, treatment patterns and outcomes, and assess the impact of therapies on disease recurrence in GPP inpatients.Methods This retrospective cohort study analyzed hospitalized patients with GPP treated at a tertiary referral center in China between March 2017 and February 2024. Patients were reassessed according to Asia-Pacific consensus criteria.Results A total of 322 inpatients with moderate-severe GPP were included, recording 419 hospitalizations. There were 212 GPP with psoriasis vulgaris (GPP+PV) and 110 GPP-PV patients, showing differences in clinical characteristics, including comorbidities. Over the 7-year study period, biologic utilization increased from 0 to 57.0%, while total annual hospitalizations decreased by 38.9%. Patients receiving biologics monotherapy demonstrated significantly better outcomes than those receiving traditional therapies, including shorter mean hospitalization duration (6.1 ± 3.4 vs. 9.2 ± 3.3 days, p < 0.001), faster pustule clearance (4.2 ± 2.6 vs. 6.8 ± 3.0 days, p = 0.001), and significantly lower recurrence rates. Multivariate analysis demonstrated, for the first time, the independent treatment effect of biologic-targeted therapy. Survival analysis confirmed significantly shorter median time to achieve GPPGA 0/1 (6 vs. 9 days, log-rank p < 0.001) and complete pustule clearance (5 vs. 11 days, log-rank p < 0.001) with biologics. Among all follow-up patients, the recurrence rate dropped from 51.7% to 29.3%, with only biologics significantly reducing flare frequency at post-discharge compared with pre-discharge (0.6 ± 0.3 vs. 1.4 ± 0.9 flares/person-year, p = 0.016).Conclusion These findings provide robust real-world evidence that biologics significantly improve both acute and long-term outcomes in GPP, supporting their use as first-line therapy and underscoring the need to improve global access to these treatments.