A case of psoriasis and multiple sclerosis succesfully treated with concomitant fingolimod and secukinumab.

Dear Editor, Psoriasis (PsO) is a chronic inflammatory disease characterized by erythemato-desquamative plaques with systemic involvement (psoriatic arthritis, metabolic syndrome, cardiovascular disorders, Crohn's disease, and depression).1 Multiple sclerosis (MS) is an auto-immune neurological disease characterized by inflammation, demyelination, gliosis, and neuronal loss. Recent epidemiological studies highlighted a possible link between PsO and demyelinating disorders such as MS.2 Herein, we reported the case of a 40-year-old female who suffered from PsO and MS successfully treated with a combination therapy of secukinumab and fingolimod. Medical history included MS which was diagnosed in 2008. Previous MS therapy included interferon-α for 7 years while she was currently on fingolimod, an unselective agonist of sphingosine 1-phosphate receptor (S1PR). She started it in 2016 with good disease control (clinical and radiological remission). At physical examination, the patient showed multiple erythemato-desquamative plaques on upper and lower extremities. She related that these lesions were intensely itchy, disturbing sleep habits, and that they had started to develop two years before. A diagnosis of psoriasis was performed, and due to the huge impact on quality of life and referred itch, she started anti-IL17 treatment (secukinumab at labelled dosage) in agreement with the neurologist and without fingolimod suspension. At week 5, the patient showed a significant clinical improvement (PASI 90 reached: PASI decreased from 12.4 at baseline to 1.2), maintaining this result up to week 12. MS remained stable during treatment (no other neurological symptoms were reported with magnetic resonance imaging [MRI] not showing any sign of disease progression) (Figure 1). Psoriasis treatment is influenced by the presence of comorbidities such as MS. Particularly, in psoriasis patients with a first-degree relative with multiple sclerosis or other demyelinating disease, European and Italian consensus suggested against the use of tumour necrosis factor (TNF) antagonist therapy due to the possibility of increasing radiologic activity of MS after anti-TNF administration.3 Conversely, secukinumab is supposed to be a valid option for patients with PsO and SM; indeed, a clinical trial showed that this anti-IL-17 drug may even reduce MRI lesion activity in MS. In contrast, to our knowledge, no cases of concomitant use of immunomodulant therapy for MS such as fingolimod and a biologic drug for PsO were registered. However, the association of fingolimod and secukinumab was already experienced in two young men with ankylosing spondylitis and MS, with successful and safe results. Furthermore, literature data may even support S1PR inhibition partial beneficial effects on psoriasis. Indeed, a phase 2 trial on psoriasis regarding ponesimod, an S1PR inhibitor like fingolimod, was conducted in 2014, even if without showing outstanding results (endpoint was PASI75).4 Moreover, Okura et al. demonstrated the efficacy of fingolimod in improving imiquimod-induced psoriasiform dermatitis in mouses, supporting S1PR inhibitors’ administration in psoriasis.5 Hence, it seems that S1PR antagonism would be even beneficial for psoriasis patients combined with biologics rather than a safety or clinical issue. To the best of our knowledge, we reported the first case of simultaneous therapy of immunomodulant treatment (fingolimod and secukinumab) in a patient with PsO and MS with clinical control of both diseases. The association of fingolimod and secukinumab seems to be a safe and efficacious option for this fragile and complicated class of patients. However, further studies are needed on this topic since only few case reports are available to support these conclusions. Luigi Fornaro: drafting the article and revising it critically for important intellectual content and giving final approval of the version to be published. Matteo Megna: have made substantial contributions to conception and design, drafting the article, and revising it critically for important intellectual content and giving final approval of the version to be published. Gabriella Fabbrocini: have made substantial contributions to conception and design, drafting the manuscript and revising it critically for important intellectual content, and giving final approval of the version to be published. Matteo Noto: have made substantial contributions to conception and design, drafting the manuscript and revising it critically for important intellectual content, and giving final approval of the version to be published. No conflict of interest. The patient gave the consent for photo acquisition and publication. Open Access Funding provided by Universita degli Studi di Napoli Federico II within the CRUI-CARE Agreement.