Efalizumab rebound response to a sequential therapy of infliximab followed by efalizumab.

weak response after 10 days of ciclosporin and the immediate need to control the systemic disease. After 4 weeks, the patient was free of pustules but a slight erythema was still present. At week 14, the patient was free of lesions, and, after the 5th infusion, she requested the suspension of infliximab. Efa lizumab was reintroduced with the maintenance of the excellent results (PASI-100) until the last follow-up visit 100 weeks after the first infliximab infusion and 58 weeks from the second cycle of efalizumab ( fig. 2 ). The generalized pustular eruption seen 5 weeks after the efalizumab withdrawal might be classified either as generalized pustular psoriasis (GPP), i.e. a rebound phenomenon after efalizumab suspension, or as a GPP relapse (second episode). We favour the rebound hypothesis because of the time of onset (5 weeks). In fact, rebound is defined as the development of new widespread pustular, erythrodermic or more inflammatory psoriasis lesions occurring within 8 weeks from treatment discontinuation in responding patients [2] . Approximately 13% of treated patients develop a rebound phenomenon [2] , although GPP after efalizumab withdrawal has rarely been reported. Gaylor and Duvic [3] reported a case of GPP occurring 2 weeks after efalizumab withdrawal, which may have been triggered by a concomitant herpes zoster infection. Infliximab has been successfully used in patients with GPP, reporting a rapid and positive response without any significant side effects [4, 5] , but, in the literature, infliximab and methotrexate resistant rebounds, as well as a paradoxical flare of pustular psoriasis with TNFantagonists, have been reported [6] . Our case showed not only an excellent response of GPP to infliximab,