[Severe erythema and pustules after antibiotic use: acute generalised exanthematous pustulosis]. / Ernstig erytheem en pustels na antibioticagebruik: Acute gegeneraliseerde exanthemateuze pustulose.

BACKGROUND: Acute generalised exanthematous pustulosis (AGEP) is a rare and self-limiting pustular cutaneous reaction to a drug or infection. CASE DESCRIPTION: A 62-year-old male presented to the Emergency Department with fever, erythema and pustules on both thighs. The initial blood analysis showed increased inflammatory parameters. The patient was admitted to the Dermatology Department with suspected AGEP. All medication was stopped. The diagnosis was confirmed histologically. During hospitalisation, the cutaneous reaction spread over 30% of the skin surface. Seven days after onset, the skin disorder regressed and the patient was discharged after 16 days. Use of amoxicillin/clavulanic acid was very likely the triggering factor for the development of AGEP. CONCLUSION: AGEP, although self-limiting, can have a fulminant course, requiring admission to a burns centre. It is imperative that rechallenge with the triggering drug is avoided.

Developing a Therapeutic Range of Adalimumab Serum Concentrations in Management of Psoriasis: A Step Toward Personalized Treatment.

IMPORTANCE: Adalimumab has proven to be effective in suppressing psoriasis disease activity and is administered in a standard dose. OBJECTIVE: To establish a therapeutic range for adalimumab trough levels in the treatment of plaque-type psoriasis, leading to a more personalized treatment. DESIGN, SETTING, AND PARTICIPANTS: A multicenter, prospective, observational, daily practice cohort study conducted at an academic hospital with affiliated secondary care hospitals in Belgium (cohort 1) and 2 academic hospitals in the Netherlands (cohort 2). Both cohorts included adult patients treated with adalimumab for plaque-type psoriasis. Cohort 1 comprised 73 patients who were being treated with adalimumab for more than 24 weeks until 401 weeks. In cohort 2 (n = 62), serum samples were obtained between weeks 24 and 52 of treatment. INTERVENTIONS: Before the start of adalimumab therapy and at time of serum sampling, Psoriasis Area and Severity Index (PASI) scores were determined. MAIN OUTCOMES AND MEASURES: Adalimumab trough level and PASI score at the time of serum sampling to determine the receiver-operator characteristics analyses and concentration effect curve. RESULTS: By means of receiver-operator characteristics analyses with an area under the curve of 0.756 (SD, 0.046; 95% CI, 0.666-0.847) and a sensitivity of 78% and a specificity of 70%, 3.51 mg/L was established as the lower margin for the therapeutic range. By means of a concentration effect curve, 7 mg/L was established as the upper margin. One-third of patients had an adalimumab trough concentration exceeding 7 mg/L. CONCLUSIONS AND RELEVANCE: A therapeutic range of adalimumab trough levels of 3.51 mg/L to 7.00 mg/L, which corresponds to an optimal clinical effect, was identified. In one-third of patients, it was observed that trough concentrations exceeded the therapeutic window. Based on the established range, a therapeutic algorithm for adalimumab treatment for patients with psoriasis can be developed and validated in a prospective patient cohort. By identifying this range, a step has been taken toward a more rational use of biological therapy in psoriasis. Developing a therapeutic algorithm may lead to less overtreatment of patients and cost savings.