What treatment approach is recommended for a patient with a history of psoriasis who has a severe, potentially life-threatening infection caused by a resistant Gram-positive organism and compromised immune system?

Management of Psoriasis in the Setting of Severe Life-Threatening Infection

Immediately discontinue all biologic and systemic immunosuppressive therapies for psoriasis until the severe infection is completely resolved, and manage the infection aggressively with appropriate antimicrobials. 1

Immediate Actions

Discontinue Immunosuppressive Therapy

• Stop all biologic agents immediately (TNF inhibitors, IL-17 inhibitors, IL-12/23 inhibitors) as these significantly increase the risk of serious infections and can impair the immune response needed to combat resistant organisms 1
• Halt any concurrent systemic agents including methotrexate, cyclosporine, or other immunosuppressants that would further compromise immune function 1, 2
• The risk of infection-related mortality outweighs any benefit of continued psoriasis control in this clinical scenario 1, 3

Infection Management Priority

• Consult infectious disease specialists immediately for management of the resistant Gram-positive organism 1
• Initiate appropriate antimicrobial therapy based on culture sensitivities and infectious disease recommendations 1
• The compromised immune system combined with biologic therapy creates a particularly high-risk scenario for treatment failure and mortality 1, 3

Psoriasis Management During Active Infection

Topical Therapy Only

• Transition to high-potency topical corticosteroids (clobetasol propionate 0.05% or betamethasone dipropionate 0.05%) for psoriasis control during the infection treatment period 4
• Combine with calcipotriene for enhanced efficacy without systemic immunosuppression 4
• These agents provide symptomatic relief without compromising immune function needed to fight the infection 4, 2

Avoid Systemic Corticosteroids

• Never use systemic corticosteroids as they can cause severe, potentially fatal deterioration of psoriasis upon withdrawal and further compromise immune function 4

Timing of Biologic Reinitiation

Infection Resolution Required

• Do not restart biologic therapy until the infection is completely resolved, documented by negative cultures, and the infectious disease team has cleared the patient 1
• Ensure adequate time has passed after infection resolution (typically several weeks minimum) before considering biologic reinitiation 1

Pre-Restart Screening

• Repeat complete blood count with differential and comprehensive metabolic panel 1
• Ensure no residual signs of infection clinically or by laboratory parameters 1
• Consider repeat imaging if the infection involved deep tissues 1

Biologic Selection After Infection Recovery

Preferred Agents Post-Infection

• IL-12/23 inhibitors (ustekinumab) are preferred over TNF inhibitors or IL-17 inhibitors for patients with a history of serious infections, as they demonstrate lower rates of serious infection recurrence 1, 3
• Apremilast (non-biologic oral agent) shows decreased rates of serious infection compared to methotrexate and may be considered for patients with recurrent infection concerns 3
• Etanercept and ustekinumab demonstrated lower serious infection rates compared to methotrexate in large claims database studies 3

Agents to Avoid

• Avoid TNF inhibitors (infliximab, adalimumab) in patients with recurrent serious infections, as these carry higher infection risk, particularly for tuberculosis and opportunistic infections 1
• IL-17 inhibitors show increased risk of cutaneous bacterial infections including cellulitis and should be used cautiously in patients with infection history 5
• Methotrexate carries baseline infection risk and should not be first-line in this population 3

Long-Term Monitoring Post-Recovery

Enhanced Surveillance

• Implement more frequent clinical assessments (every 4-8 weeks initially) after restarting biologics in patients with prior severe infection 1
• Maintain yearly tuberculosis screening (PPD, T-Spot, or Quantiferon Gold) with lower threshold for testing if any concerning symptoms develop 1
• Monitor complete blood count and comprehensive metabolic panel every 3-6 months 1

Patient Education

• Instruct patients to immediately report fever, new skin lesions, cellulitis, or any signs of infection 1, 5
• Emphasize that early detection and temporary drug cessation may prevent life-threatening complications 1

Critical Pitfalls to Avoid

• Never continue biologics during active serious infection – the mortality risk is unacceptable 1, 3
• Do not use combination immunosuppressive therapy (e.g., biologic plus methotrexate) in patients with infection history, as this compounds infection risk 1, 6
• Avoid antimalarial agents (hydroxychloroquine, chloroquine) permanently in psoriasis patients as these can cause severe, potentially fatal psoriasis exacerbation 7, 4, 8
• Do not restart biologics based solely on psoriasis severity – infection clearance must be definitively documented first 1