Long-Term Control of Generalized Pustular Psoriasis Achieved With Subcutaneous Spesolimab Following Severe Flare

Generalized pustular psoriasis | Image Credit: © DermNet

At the 2025 Society of Dermatology Physician Associates (SDPA) Annual Summer Dermatology Conference, a poster shared details of a case report on the management of generalized pustular psoriasis (GPP).¹

The poster highlighted how prompt initiation of intravenous (IV) spesolimab (Spevigo; Boehringer Ingelheim Pharmaceuticals, Inc.) during an acute GPP flare followed by ongoing subcutaneous spesolimab therapy achieved not only rapid disease control but also sustained remission for over a year in a medically complex patient.

GPP flares, especially involving systemic inflammation, fever, and erythema, may escalate into serious complications, particularly in elderly or comorbid patient populations.² A 2023 review published in Dermatology and Therapy reported that untreated GPP flares and pustular eruptions may lead to life-threatening effects, including sepsis and cardiovascular failure.²

The case reported was that of a 72-year-old African American woman with significant medical history, including type 2 diabetes, chronic kidney disease, vascular dementia, COPD, and a prior GPP flare 3 years prior to presentation.

Just one month prior to hospitalization, she began experiencing symptoms of a GPP flare. Emotional stress from the recent loss of her sister was believed to be the trigger. Despite widespread pustules, erythroderma, pain, and fever, she delayed seeking care, which led to an array of complications.

Upon admission, she met multiple criteria defined by the global Delphi consensus for GPP,³ including systemic symptoms (fever of 102°F, chills), leukocytosis (WBC count of 20.6 x 10⁹/L), elevated ESR (75 mm/h), and histological findings of subcorneal pustules and dermal inflammation.

Initial topical therapies failed to improve her symptoms. The clinical team proceeded with IV spesolimab 900 mg, administered on days 4 and 10 of hospitalization.

The response was both significant and rapid in nature; within 48 hours of the first infusion, near-complete pustular resolution was noted, with full clearance and pain relief achieved only 1 week post-treatment.

Despite dermatologic improvement, the patient experienced severe systemic complications due to delayed treatment, including distributive shock, acute kidney injury, hypothermia, and lactic acidosis. She required intubation, intensive care unit admission, and a hospital stay lasting longer than a month. During this time, clinicians briefly administered oral cyclosporine in an effort to stabilize systemic inflammation.

Although her skin cleared by day 14, the systemic impact was lasting. Her quality of life deteriorated rapidly, and she required transfer to a skilled nursing facility for rehabilitation. She was unable to return to independent living.

Following discharge from the hospital, clinicians initiated maintenance therapy with subcutaneous spesolimab 300 mg every 4 weeks, beginning 5 days post-discharge. The loading dose was omitted due to recent IV administration.

Over the next 12 months, the patient did not experience a single documented disease flare. While she developed mild, superficial scaling in the days leading up to her monthly doses, this low-grade desquamation was fully controlled by each subsequent injection. No safety concerns were reported during this period.

The case highlights several critical points about the management of GPP.

IV spesolimab provided near-immediate control of the acute flare, even in a severely ill, elderly patient. Furthermore, subcutaneous spesolimab maintained long-term disease suppression, eliminating recurrent flares.

The patient's prolonged untreated flare led to multiorgan complications and irreversible declines in function, highlighting the need for early dermatologic intervention. As GPP is increasingly recognized as a chronic, relapsing condition, this case supports a proactive treatment strategy aimed at both rapid control and sustained remission.

References

1. Chadha AA. Long-term management of chronic generalized pustular psoriasis with subcutaneous spesolimab: a case report. Poster presented at: Society of Dermatology Physician Associates (SDPA) 2025 Annual Summer Dermatology Conference; June 26-29, 2025; Washington, DC.
2. Rivera-Díaz R, Daudén E, Carrascosa JM, Cueva P, Puig L. Generalized pustular psoriasis: a review on clinical characteristics, diagnosis, and treatment. Dermatol Ther (Heidelb). 2023;13(3):673-688. doi:10.1007/s13555-022-00881-0
3. Barker JN, Casanova E, Choon SE, et al. Global Delphi consensus on treatment goals for generalized pustular psoriasis. Br J Dermatol. 2025;192(4):706-716. doi:10.1093/bjd/ljae491

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