Lack of efficacy of etanercept in acrodermatitis continua of Hallopeau

A 40‐year‐old man was referred to our department in January 2000 with persistent, scaly, pustular and tender plaques on the distal portion of the digits. He first noted pustulation around the nail, which was followed by scaling and crust formation, and subsequently led to nail dystrophy. Earlier treatment had included topical antibiotics, antimycotics, and corticosteroids, as well as systemic antibiotics, without any success. His past medical history was otherwise unremarkable. Post‐traumatic fingertip amputation of the third finger of the right hand was repaired with a full‐thickness skin graft. On dermatologic examination, there was a severe erythematosquamous, psoriasiform, pustular eruption surrounded by a hyperemic area affecting the terminal phalanges of nine of the 10 digits. The skin of the graft was intact. Examination of the digits revealed anonychia of six of the 10 fingernails (Fig. 1) The rest of the physical examination was normal. Clinical and histologic findings led to the diagnosis of acrodermatitis continua of Hallopeau (ACH). X‐Rays of both hands showed osteolysis of two of the 10 terminal phalanges. 1 Before therapy: acrodermatitis continua of Hallopeau demonstrating acral pustule formation Initial therapy was with acitretin (up to 1 mg/kg). This treatment produced moderate clinical improvement, but was discontinued after 4 months because of a sudden increase in serum lipids. Treatment with topical corticosteroids under occlusion, combined with psoralen plus ultraviolet A (PUVA) twice weekly, was started, but this gave only a slight improvement. Over the following 5 months, the patient developed generalized pustular psoriasis. Treatment was therefore started with methotrexate (intravenously, 25 mg weekly) in combination with fluocortolone (0.5 mg/kg body weight/day). Methotrexate was stopped after 6 weeks because of a sudden increase in liver transaminases and a lack of efficacy. The patient was subsequently lost to follow‐up for more than 6 months. Until the time of presentation to our outpatient clinic, he had continued topical corticosteroids. He was admitted to our department and therapy with cyclosporine (5 mg/kg/day) was started. After 4 weeks the condition still remained active and the patient refused further doses of the drug. We therefore started topical therapy with tacrolimus 0.1% ointment (Protopic) twice daily under occlusion. This therapy gave only a slight improvement and was later replaced by mycophenolate mofetil (up to