Tildrakizumab Ineffective in Generalized Granuloma Annulare
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Generalized granuloma annulare is a widespread inflammatory condition that can have a significant impact on quality of life. Treatment remains a challenge, as evidenced by the evergrowing list of therapeutic options. Part of the difficulty for treatment remains in the incomplete understanding of its immunopathogenesis. The effectiveness of the tumor necrosis factor alpha inhibitor class has highlighted the role of a T helper (Th)1 – mediated delayed type hypersensitivity reaction but not all patients are responders and there are also cases of paradoxical granuloma annulare after starting treatment.

A case of generalized granuloma annulare with tildrakizumab, an anti–interleukin-23p19 monoclonal antibody approved for treatment of plaque psoriasis is reported. A 58-year-old woman with a past medical history of hypertension, hyperlipidemia, hypothyroidism and depression presented with over a 10-year history of widespread annular dermal plaques involving her face, neck, arms, torso and legs.

Histopathology was consistent with granuloma annulare. Patient completely cleared with adalimumab but had to discontinue treatment after a lapse in insurance coverage, which led to a relapse of her disease. Based on a case report of ustekinumab, an IL-12/23 inhibitor, successfully treating granulomatous dermatitis in the setting of necrobiosis lipodica, it was decided to start treatment with tildrakizumab, a selective IL-23 inhibitor.

Tildrakizumab 100 mg was administered subcutaneously at weeks 0, 4 and then every 12 weeks consistent with the approved psoriasis dosing. At her 28-week follow-up, patient did not show any appreciable improvement and elected not to continue with treatment. The inefficacy of tildrakizumab in this case adds to the growing body of literature that the IL-23/Th17 pathway does not play a central role in the immunopathogenesis of granuloma annulare.

Source: https://www.jaadcasereports.org/article/S2352-5126(20)30781-5/fulltext?rss=yes