Inpatient Use of Biologics for Generalized Pustular Psoriasis and DRESS

The talk reviewed inpatient use of biologics through two challenging dermatology cases. The first was a 77-year-old man with acute diffuse erythroderma and numerous pustules after a recent prednisone taper, ultimately diagnosed as generalized pustular psoriasis (GPP) based on morphology, biopsy, and a history of prior psoriasiform plaques. After he became hemodynamically unstable from diuresis and required ICU care, he received IV spesolimab, an IL-36 receptor antagonist, with rapid improvement in pustules and near-clearance within days. The speaker emphasized GPP pathophysiology involving IL-36 and IL-17 crosstalk, noting that spesolimab may be especially effective in patients with IL-36 pathway mutations or those without broader psoriatic disease, while patients with background psoriasis may need longer-term systemic planning such as cyclosporine, IL-17 blockade, or other agents. The second case was a 69-year-old man on prolonged ceftriaxone and ampicillin for endocarditis who developed a morbilliform rash, eosinophilia, and transaminitis consistent with DRESS. Because of ongoing infection risk, the team initially avoided broad immunosuppression and used benralizumab, an IL-5 receptor blocker, which quickly drove eosinophils to zero; prednisone was later added briefly to control persistent organ involvement, and the patient recovered. The presentation highlighted IL-5 inhibition as a steroid-sparing or adjunctive option for refractory DRESS, especially when immunosuppression should be minimized, and noted that benralizumab may work well as a one-time dose. The speaker also mentioned that IL-17 blockade is being explored for AGEP, though evidence remains limited.