Psoriasis (Chronic Plaque, Recalcitrant)

Resumen para el Paciente

¿Está esto autorizado por FDA para este uso?

Not FDA-cleared for psoriasis. FDA cleared medicinal leeches only for venous congestion in microsurgical reconstruction (K040187, June 2004). Use for chronic plaque psoriasis is investigational.

¿Qué evidencia existe?

Tier C (investigational). One small case series (n=14) reports PASI score reduction of 30-50 percent at 16 weeks; there are no randomized controlled trials. Evidence-based therapy for recalcitrant chronic plaque psoriasis: biologic rotation (anti-TNF, anti-IL-17, anti-IL-23, anti-IL-12/23), methotrexate, cyclosporine, apremilast, and phototherapy. AAD-NPF guidelines recommend stepwise escalation before experimental adjuncts. Localized leech effects do not address the systemic IL-23/Th17 axis driving disease.

Riesgos principales

• Bleeding from bite sites for 6 to 24 hours after detachment
• Koebner phenomenon — new psoriatic plaques at bite sites
• Itching, redness, and irritation at bite sites lasting days to weeks
• Local skin infection or, rarely, Aeromonas infection from leech gut bacteria
• Allergic reaction to leech saliva (uncommon)
• Post-inflammatory hyperpigmentation, especially in darker skin
• Worsening psoriasis if biologic therapy is interrupted
• Delay of evidence-based biologic rotation or systemic therapy

Quién no debería considerar esto

• Patients with erythrodermic or pustular psoriasis (systemic-therapy emergency)
• Patients with active immunosuppression and severe neutropenia from biologics
• Patients with psoriatic arthritis and active joint destruction (rheumatologic priority)
• Patients on anticoagulants, with hemophilia, or with severe anemia
• Pregnant or breastfeeding patients
• Patients who have not been offered biologic rotation by a dermatologist

Qué preguntar a su clínico

• Have I tried at least 2-3 biologic classes (anti-TNF, anti-IL-17, anti-IL-23) before experimental therapy?
• Am I a candidate for methotrexate, cyclosporine, apremilast, or phototherapy?
• What evidence supports leech therapy for psoriasis like mine?
• Will leech bites risk triggering Koebner plaques?
• Are leeches from an FDA-registered supplier and used only once?
• What is the practitioner's Aeromonas-prevention plan?
• What is the cost and is it covered by insurance? (typically not covered)

Cuándo buscar atención urgente

• Rapidly spreading redness with pustules or peeling skin (suspect erythrodermic / pustular psoriasis — emergency)
• Fever above 38.0 C / 100.4 F or chills
• Spreading redness, warmth, pus, or red streaks (cellulitis)
• Bleeding from a bite site lasting more than 24 hours
• Severe new joint pain or swelling (psoriatic arthritis flare)
• Hives, facial or tongue swelling, throat tightness, or breathing difficulty