Treatment of Genital, Scalp and Face Psoriasis with Risankizumab

Psoriasis affecting the face, scalp, hands, feet, nail and genitals may cause disproportional impact on quality of life despite the small surface area compromised [1]. Genital psoriasis (GenPs) can affect 33 to 63% of psoriasis patients at any time during their lives [2]. Patients of any age can have such lesions and males might have a higher prevalence. In males, the shaft of the penis is the most commonly affected area followed by the scrotum and glans penis. In females, those areas are the labia majora, perineum and labia minora [1]. 

Symptoms reported by patients with GenPs are itch, pain, dyspareunia, worsening of genital psoriasis after intercourse and decreased frequency of intercourse, all correlated with high impact on quality of life [1]. 

Even though GenPs is relatively common, these lesions may be under-reported and underdiagnosed because of embarrassment of patients, unfamiliarity with the disease or concerns about having a sexually transmitted disease [2]. 

Several effective treatments have been reported for plaque psoriasis, however there are few studies and reports regarding GenPs treatment. We report here a case of successful treatment of a patient with genital, face and scalp psoriasis with risankizumab, an anti-IL23 drug.

Male, 33 years-old, had scalp psoriasis for 10 years. On the last year, lesions on scalp worsened affecting almost all scalp with thick lesions and intense itching that commonly led to secondary bacterial infections and the genital area, including the glans penis and scrotum, was compromised. The patient complained about embarrassment at work related to lesions on visible area on his face and sexual distress, anxiety and symptoms of depression and itching related to genital lesions. 

He used topical corticosteroids from low to high potency, combinations of corticosteroids with vitamin D analogous, emollients both on scalp and genital with partial response and was taking methotrexate for more than 3 months without response. Because of intense itching and disturbs related to genital lesions, he was applying clobetasol ointment every day on this area, unaware of the risks related to this inapropriate self-treatment. 

Risankizumab was prescribed as 150 mg when patients Physician’s Global Assessment of Genitalia (sPGA-G) scale was 3 and Scalp Physician’s Global Assesment scale (ScPGA) was 4, DLQI 18. We advised the patient to avoid applying any corticosteroids.After two doses (week 0 and 4), scalp psoriasis remitted and patient reached sPGA-G 1 and ScPGA 0 (Figures 1,2 &3). Relating significant satisfaction with treatment and had no adverse effects. Genital lesions remitted at week 18. Patient kept treatment with Risankizumab 150 mg every 12 weeks and maintain response until last visit (after 1,5 years). 

 Figure 1: Scalp lesions before treatment and 2 weeks after risanquizumab 150 mg  

Figure 2: Scalp lesions before treatment and 2 weeks after risanquizumab 150 mg.  

Figure 3: Genital lesions before risanquizumab treatment and 18 weeks later.

Psoriasis patients with lesions on visible and genital areas can suffer for stigmatization and have disturbs on their professional, personal and sexual life but is often under-reported [3]. 

Few case reports are related to genital psoriasis topical treatments. These includes topical treatments with low to high-potency steroids and combinations with vitamin D analogues relating clearing genital lesions but there are few data about adverse effects on long term usage [4]. One randomized, double-blind study compared calcitriol ointment with tacrolimus ointment both twice daily for facial or genital psoriasis. Results favored tacrolimus but they don’t specify which region was compromised [5]. 

Regarding systemic treatment, methotrexate was used successfully for genital psoriasis in one report but it was related to gastrointestinal disturbance and other adverse effects [6]. Two cases were treated with oral dapsone, one with mycphenolate mofetil and another with doxepin also reporting effectiveness [7-9]. 

In relation to biologics, only ixekizumab, an IL-17A inhibitor, reported a randomized phase III clinical trial for GenPs and demonstrated statistically significant results: 74% of patients achieved PGA-G 0/1 by week 12 versus 8% of placebo. Also, more patients on ixekizumb reported improving on sexual frequency and reduction of genital itching [6]. 

Another prospective study with twenty-five woman with GenPS reported a statistically significant response with anti-IL17 (secukinumab, ixekizumab) and anti-IL12/23 (ustekinumab) and no relevant improvemet with anti-TNFα drugs [10]. 

Risankizumab is a humanized monoclonal antibody that binds subunit p19 from interleukin 23 which proved high effectiveness on plaque psoriasis in controlled randomized clinical trials and demonstrated superior efficacy to utekinumab and adalimumab regarding plaque psoriasis [11,12]. Results on GenPs synptomns were not acessed. 

In order to contribute to the knowledge of GenPS treatments, we reported here a case treated with risankizumab that demonstrated significant and rapid response on genital and scalp psoriasis without adverse effects.

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