Erythrodermic Psoriasis — SCE Dermatology MCQ

Correct answer: B — Ciclosporin and Infliximab

The correct answer is B, Ciclosporin and Infliximab. In severe, unstable erythrodermic psoriasis requiring urgent disease control, rapid onset of action is the key discriminator, and these are the two systemic agents recognised as first-line rescue options because of their fast effect compared with other conventional systemics. Ciclosporin acts within days to a few weeks via calcineurin inhibition and T-cell suppression, making it suitable for hospitalised patients needing quick stabilisation. Infliximab, an anti-TNF monoclonal antibody given intravenously, produces the fastest response among biologics, often within days, and is reserved in UK practice for patients who fail, are intolerant of, or have contraindications to standard systemic therapy in this emergency setting. Both drugs are supported by British Association of Dermatologists guidance as appropriate for severe, unstable psoriasis needing rapid control. Why the other options are wrong: C. Mycophenolate and Hydroxychloroquine: Neither has an established rapid-onset role in erythrodermic psoriasis; hydroxychloroquine can actually provoke or worsen psoriasis flares and is not used in this indication. E. Prednisolone and Thalidomide: Systemic corticosteroids are specifically avoided in psoriasis because of the well-recognised risk of severe rebound flare, including pustular or erythrodermic transformation, on dose reduction or withdrawal; thalidomide has no recognised role in psoriasis rescue therapy. A. Azathioprine and Dapsone: Both are slow-acting immunomodulators with no evidence base for erythrodermic psoriasis and are not part of standard rescue pathways. D. Methotrexate and Acitretin: Both are effective conventional systemic agents but act too slowly (weeks) for emergency stabilisation, and acitretin can transiently worsen erythroderma due to its irritant, drying effect on already compromised skin. Key point: In unstable erythrodermic psoriasis, choose the fastest-acting agents, ciclosporin or infliximab, and avoid systemic steroids because of rebound flare risk.

Reference: British Association of Dermatologists (BAD): Guidelines for biologic therapy for psoriasis 2020 (rapid update); and BAD guidance on management of erythrodermic/unstable psoriasis recommending ciclosporin or infliximab for rapid disease control. https://onlinelibrary.wiley.com/doi/10.1111/bjd.19039