Lack of efficacy of etanercept in acrodermatitis continua of Hallopeau
Authors: Adişen Esra , Öztaş Murat , Gürer Mehmet Ali 
Published: November 2007

A 40‐year‐old man was referred to our department in January 2000 with persistent, scaly, pustular and tender plaques on the distal portion of the digits. He first noted pustulation around the nail, which was followed by scaling and crust formation, and subsequently led to nail dystrophy. Earlier treatment had included topical antibiotics, antimycotics, and corticosteroids, as well as systemic antibiotics, without any success. His past medical history was otherwise unremarkable. Post‐traumatic fingertip amputation of the third finger of the right hand was repaired with a full‐thickness skin graft. On dermatologic examination, there was a severe erythematosquamous, psoriasiform, pustular eruption surrounded by a hyperemic area affecting the terminal phalanges of nine of the 10 digits. The skin of the graft was intact. Examination of the digits revealed anonychia of six of the 10 fingernails (Fig. 1) The rest of the physical examination was normal. Clinical and histologic findings led to the diagnosis of acrodermatitis continua of Hallopeau (ACH). X‐Rays of both hands showed osteolysis of two of the 10 terminal phalanges.Before therapy: acrodermatitis continua of Hallopeau demonstrating acral pustule formationimageInitial therapy was with acitretin (up to 1 mg/kg). This treatment produced moderate clinical improvement, but was discontinued after 4 months because of a sudden increase in serum lipids. Treatment with topical corticosteroids under occlusion, combined with psoralen plus ultraviolet A (PUVA) twice weekly, was started, but this gave only a slight improvement. Over the following 5 months, the patient developed generalized pustular psoriasis. Treatment was therefore started with methotrexate (intravenously, 25 mg weekly) in combination with fluocortolone (0.5 mg/kg body weight/day). Methotrexate was stopped after 6 weeks because of a sudden increase in liver transaminases and a lack of efficacy. The patient was subsequently lost to follow‐up for more than 6 months. Until the time of presentation to our outpatient clinic, he had continued topical corticosteroids. He was admitted to our department and therapy with cyclosporine (5 mg/kg/day) was started. After 4 weeks the condition still remained active and the patient refused further doses of the drug. We therefore started topical therapy with tacrolimus 0.1% ointment (Protopic) twice daily under occlusion. This therapy gave only a slight improvement and was later replaced by mycophenolate mofetil (up to 3 g/day) because of failure to improve the patient's symptoms. Response to this treatment was rather limited, even after the addition of cyclosporine. Because of the initial success with acitretin, therapy with acitretin 35 mg daily was started again. Despite using a lipid‐lowering agent, serum lipids again increased rapidly. Further systemic therapies were tried. These included dapsone (200 mg/day), cyclosporine (200 mg/day) in combination with acitretin (35 mg/day), and acitretin in combination with PUVA twice weekly for 9 weeks. All were unsuccessful. Because of recent publications reporting success in the treatment of ACH with anti‐tumor necrosis factor‐α agents, therapy with etanercept (Enbrel®, Wyeth) was considered. Purified protein derivative of tuberculin test was performed and found to be negative. Chest X‐ray was also normal. Etanercept was initiated at a dose of 25 mg subcutaneously twice weekly in combination with topical corticosteroids. The response to etanercept therapy has been reported to be dose dependent, and therefore the dose was increased to 50 mg twice weekly after the second injection. The patient tolerated the therapy without any reactions or adverse effects; his blood count, liver enzyme levels, and renal function remained normal throughout treatment. The patient is now on the 12th week of therapy, but his condition still remains active and has spread proximally (Fig. 2).After 12 weeks of etanercept monotherapyimage