Spesolimab for treatment of generalized pustular psoriasis of pregnancy.

INTRODUCTION: Generalized pustular psoriasis (GPP) is a severe, desquamating skin disorder associated with pregnancy that presents as fever, fatigue, malaise and sterile pustules. It is associated with profound maternal morbidity, maternal mortality, placental insufficiency and stillbirth. Treatment often includes glucocorticoids that are continued until delivery. Monoclonal antibody spesolimab was approved for treatment of GPP in 2022 but there is a paucity of pregnancy data. CASE: A 39-year-old multiparous African American patient with chronic hypertension presented at 19 weeks gestational age with scaling rash, which progressed to blistering and sloughing several days later. She required burn intensive care. Her disease was refractory to high-dose glucocorticoids, cyclosporine and TNF-α inhibitors. Ongoing corticosteroid usage exacerbated her hypertension and resulted in hyperglycemia. Spesolimab was administered, which resulted in a rapid resolution of GPP within days of administration, and this was maintained throughout her pregnancy. There were no sustained maternal or fetal effects and she delivered a healthy term neonate. CONCLUSIONS: Treatment with spesolimab rapidly improved symptoms of GPP refractory to other immunomodulators. This is the first published use of spesolimab in a pregnant patient in the United States. We suggest that spesolimab may offer rapid, safe relief of severe immunologic disease in pregnancy, though further study is required.