Abstract
Despite the revolution represented by biologic drugs, it is safe to say that every dermatologist has known the frustrating experience of treating a “difficult” patient with psoriasis. Such patients may have been treated with numerous drugs, never achieving long-term disease control. We hereby present the case of a patient who, despite having been treated, over the course of 15 years, with 7 biologics and 3 traditional systemic agents, has never experienced lasting remission. We also discuss hypothetical reasons for these repeated treatment failures: while obesity and ANA positivity could have contributed significantly, a third, more complex, factor may be to blame. It is possible that frequently switching to the newest drug available, due to lack of other therapeutic options, interfered with the pathogenetic phenotype of the patient, and, consequently, with the response to other biologics. This disheartening and fascinating hypothesis clearly needs to be investigated, in the hope of finding solutions for all seemingly impossible-to-treat patients.
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