# Treatment Strategies in Neutrophil Dermatoses: A Comprehensive Review
## 5 Generalized Pustular Psoriasis
### Treatment
#### 5.3.6 Biological Treatment  
TNF-\(\alpha\) Inhibitors  
Many case reports describe the efficacy of TNF-\(\alpha\) inhibitors. However, a paradoxical reaction after administration has been reported. The physiopathology of this event is not fully understood. See Table 4.  
**Infliximabb**  
In a retrospective study, the administration of infliximab in a standard regimen (intravenous infusion at weeks 0, 2, and 6, and subsequently every 4 weeks) demonstrated flare control in four patients after 24-48 h of the infusion. Additionally, in an open-label study that included 10 patients with GPP flares, the time to pustular clearance ranged from 1 to 8 days [103]. **Adalimumabb**  
Adalimumab was described as effective and well tolerated for up to 52 weeks in 10 Japanese patients. Time to remission was variable, from 1 to 4 weeks [89]. **Etancerpt**  
A case series that included six patients with GPP showed a reduction in inflammatory biomarkers and clinical improvement [103]. IL-17A Inhibitors  
**Brodalumab**  
In an open-label, multicenter, long-term, phase III study, patients showed improved clinical status or remission after 12 weeks of treatment. By week 52, 91.7% were in clinical remission or had improved clinical status with the administration of brodalumab, an IL-17 receptor antagonist [96]. **Secukinumab** \begin{table}
\begin{tabular}{c c c} \hline \hline
**Biological Agent** & **Dosage** & **Reference** \\ \hline \hline \multirow{2}{*}{Etancercept} & \multirow{2}{*}{50 mg of etanercept twice weekly subcutaneously} & [94] \\ \cline{2-3}  & & \\ \hline \multirow{2}{*}{Infliximabb} & \multirow{2}{*}{5 mg/kg body weight is administered on week 0, 2, 6, and} & \\  & then regularly every 8 weeks & \\ \hline \multirow{4}{*}{Adalimumabb} & Dose of 80 mg is given s.c. in adults, and after the second & \\  & week, a dose of 40 mg is given s.c. every 2 weeks. If the & \\  & efficacy is insufficient, the dose may be increased to & \\  & 80 mg/administration & \\ \hline \multirow{2}{*}{Brodalumab} & s.c. injections of 210 mg at weeks 0, 1, 2 and then every & \\  & 2 weeks thereafter & \\ \hline \multirow{2}{*}{Secukinumab} & Weekly s.c. injections of 300 mg on weeks 0, 1, 2, 3, and 4, and & \\  & then every 4 weeks thereafter (may be decreased to 150 mg) & \\ \hline \multirow{2}{*}{Ikekizumabb} & s.c. injections of 160 mg at week 0, followed by 80 mg at & \\  & weeks 2, 4, 6, 8, 10, and 12, then 80 mg every & \\  & 4 weeks thereafter & \\ \hline \hline \end{tabular}
\end{table} 
Table 4: Biological agents in the treatment of generalized pustular psoriasis. Secukinumab is a monoclonal antibody that targets IL-17A, which demonstrated efficacy in a phase III study that included 12 patients with GPP in Japan. It was used as a monotherapy or in combination with other immunosupuppressant drugs, and resulted in 9/12 patients (75%) achieving a Clinical Global Impression (CGI) score of \"very much improved\" at week 12, along with 7/12 patients (58.3%) achieving this at week 52 [89; 94];  
**Ixekizumab**  
Another IL-17A antagonist, similar to secukinumab, is ixekizumab; efficacy has been demonstrated in patients with GPP in three phase III, open-label, multicenter studies, which included Japanese patients with GPP [89; 104]. Anti IL-23 and IL-23/IL-12 Inhibitors  
**Guselkumab**  
Guselkumab is an IL-23 inhibitor that showed efficacy in a phase III, multicenter, open-label study in Japan that included 10 patients with GPP. In total, 50% of the patients showed improvement after one week of the administration of guselkumab [97]. **Risankizumab**  
Risankizumab targets the p19 subunit of IL-23 and was approved in Japan for the treatment of patients with GPP [98; 105]. Anti IL-1\(\beta\) and IL-1R Inhibitors  
**Anakinra**  
Anakinra is a recombinant IL-1 receptor antagonist, showing efficacy in reducing symptoms, normalizing inflammatory biomarkers, and stopping pustule formations in a patient with GPP and IL36 RN mutation after 5 month of treatment [99].