Treatment of Psoriasis Unresponsive to Enstilar in Patients with Brittle Diabetes

Introduction to Biologic Therapies

The American Academy of Dermatology recommends TNF-alpha inhibitors (adalimumab, etanercept, or infliximab) as the preferred next-line systemic therapy for patients with psoriasis unresponsive to Enstilar, due to their lack of known drug interactions, no deleterious effects on renal function or blood pressure, and no significant impact on glucose control when diabetes is well-managed 1, 2
Biologic therapies, such as TNF-alpha inhibitors, offer significant advantages in patients with complex medical histories on multiple medications, with no relevant drug interactions and no known deleterious effects on renal function or blood pressure 1

In patients with active psoriatic disease and diabetes, TNF inhibitors may be considered when diabetes is well controlled, particularly if the patient has severe or extensive skin disease 2, 3
TNF-alpha inhibitors are FDA pregnancy category B and have fewer significant safety issues compared to traditional systemic agents 1

The American Academy of Dermatology notes that methotrexate carries increased hepatotoxicity risk in patients with diabetes due to potential underlying steatohepatitis, making it a less attractive option 4, 1
Cyclosporine has a high probability of exacerbating hypertension, a common comorbidity in diabetic patients, and is nephrotoxic 4, 1
Acitretin causes elevations in serum transaminases and triglycerides, which are particularly problematic in diabetic patients who often have dyslipidemia 4, 5

IL-17 inhibitors may be conditionally recommended over TNF inhibitors in patients with diabetes, based on very-low-quality evidence 2, 3
IL-12/23 inhibitors, such as ustekinumab, may be preferred over TNF inhibitors in diabetic patients based on conditional recommendation from very-low-quality evidence 2, 3

The American Academy of Dermatology advises against using systemic corticosteroids, as they can precipitate severe psoriasis flares upon discontinuation 6
Medications that worsen psoriasis, such as lithium, chloroquine, beta-blockers, and NSAIDs, should be avoided 8
Cyclosporine should be avoided in patients with any degree of renal impairment or uncontrolled hypertension, both common in brittle diabetics 4, 1