**1. Introduction**

272 Psoriasis

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M. (2003). Novel mechanism of T-cell and dendritic cell activation revealed by profiling of psoriasis on the 63,100-element oligonucleotide array. *Physiol Genomics*, Psoriasis is a disease with frequently severe impairment of quality of life. Traditional therapies (topical treatments, UV, cyclosporine, acitretin, methotrexate...) are widely used but are not always sufficient, and may be poorly tolerated or contra-indicated. Among biologicals, firsts on the European dermatological market were etanercept and infliximab. Alefacept use was restricted to the United States of America. Byafter, adalimumab and ustekinumab were launched.

Among all these biotherapies, infliximab is considered a little bit different : known to be one of the most efficient, infliximab treatment requires a mode of administration quite repulsive for some practitioners. It is an intravenous drug, needing a medicalized center of care with good experience and equipment. Infliximab is also known to induce some adverse event, particularly infusion hypersensitivity.

To verify these sentences, we intended to examine our patient cohort treated by infliximab in our Dermatology Unit, with a retrospective study of the first 50 patients beginning infliximab therapy in our Department (excluding patients in phase II or III clinical trials).

Aims :


Limitations :


Infliximab Therapy for Plaque Psoriasis: The UCL Experience 275

Our patients' demographic data is unremarkable: average weight, alcohol and tobacco habits, comorbidity, and concurrent medication appear to be similar to the general population of psoriasis patients. Only the sex ratio would seem to be non-standard: there are significantly less women than men in our series (13 vs 33). Even if it is not consistent with the general psoriasis sex ratio, it is in accordance with other infliximab case series.

For legal, and social security reimbursement reasons, we do not prescribe infliximab to children and adolescents; our youngest patient is aged 19 years. Subject to a safeguarded

Prior treatments received for psoriasis are stereotypical: before authorizing biological therapy, Belgian regulations require patients to have tried three therapeutic channels: PUVA therapy, cyclosporine, and methotrexate. It is noted that this refers to PUVA therapy proper, and not just UVB treatment. For cyclosporine, a 'minimum of 2 months of therapy' is stipulated, 'at a minimum of 2.5 mg/kg.day'. For methotrexate, a minimum of 3 months is required, at 15 mg minimum per week. Infringements to either requirement can be made

Among the 46 patients, one was Argentinian and had been able to begin biological therapy in his country without going through the three prior steps; the Belgian authorities therefore authorized him to take infliximab immediately. Another patient had mild renal insufficiency and unstable blood pressure despite the treatment, which was deemed sufficient to certify contra-indication to cyclosporine. The remaining 44 patients all received the three standard treatments, in some cases also UVB, acitretin, or spa treatments. None received fumaric acid (not used in Belgium). Reasons for discontinuing prior treatments included the absence of sufficient clinical results, or an intolerance to the treatment, as well as the prevention of side affects after reaching an excessive cumulative dose. Note: one of the patients had renal

No regulations lay down the use of a specific first-line biological therapy. It would no doubt be logical to begin with a TNF inhibitor, before considering an anti-interleukin, such as ustekinumab, however no objective data exists to support this affirmation. This rationale lies merely in a lack of experience and appraisal with ustekinumab, as opposed to the years of experience with TNF inhibitors, infliximab in particular. There is no way to choose one product over another among TNF inhibitors. Suggestions to begin with etanercept are based on certain data emerging from records, but these are not sufficiently back-up. In the end, the choice of first-line biological therapy currently depends on the habits of the prescriber and

In our case series, 15 patients have received infliximab as first-line treatment. The choice was laid out by presenting the patient with the different options, along with their known

general condition, we did not set an upper limit; the oldest patient was aged 72.

only in the case of documented intolerance or absolute contra-indication.

insufficiency induced by prolonged cyclosporine therapy.

**3.3 Choice of biological therapy** 

discussions with the patient.

**3. Discussion 3.1 Population** 

**3.2 Prior systemic treatment** 

