COX-2 inhibitor.

he developed severe psoriasis responsive only to repeated courses of the then newly available PUVA (psoralen plus UVA radiation) therapy. Between 1973 and 1993 he received PUVA once a week. During treatment no genital protection was used although he had never received UV therapy directly to the genital area. Two years after the onset of psoriasis he developed peripheral inflammatory arthritis. Having tried gold, sulphasalazine and steroid therapy with little success, in 1995 he was started on methotrexate therapy, which he has been on ever since. His joint disease continued to progress and in July 2003 he was commenced on infliximab (at a dose of 3 mg/kg administered by intermittent intravenous infusion). Initially both his psoriasis and psoriatic arthropathy responded well; however, his joint disease relapsed and in November 2004 his therapy was switched to etanercept (25 mg twice weekly administered subcutaneously). A failure to improve after 6 months led to etanercept being withdrawn and he continued with methotrexate monotherapy (at a dose of 22.5 mg weekly). Six months after commencing anti-TNF therapy he developed an actinic keratosis on his nasolabial fold and biopsy confirmed Bowen's disease of his trunk and left upper cheek. Reactivation of viral infections, especially papillomas was also noted. Two months after stopping anti-TNF treatment a lesion on his glans penis was removed: histological examination demonstrated a moderately differentiated squamous cell carcinoma. He has subsequently developed multiple superficial basal cell carcinomas on his trunk which have been treated with imiqumod. A 66-year-old man, the elder brother of the above patient, developed psoriasis and inflammatory arthritis at the age of 17. His psoriasis was not as severe as his younger brother's, and although treated initially with a short course of UVB therapy, he was never exposed to UVA or PUVA. The mainstay of his psoriasis treatment was topical therapy. After an initial severe episode of synovitis at the onset of his psoriasis, his joint symptoms were quiescent until at the age of 60 when he developed extensive peripheral inflammatory arthritis and was commenced on methotrexate (with the dose gradually being increased to 25 mg/week). This failed to control his arthritis. The addition of azathrioprine (100 mg twice daily) and subsequently of cyclosporine (2.5 mg/kg) was associated with side effects (the development of blood dyscrasias and hypertension, respectively) and these drugs were subsequently discontinued. In January 2004 he was commenced on infliximab (at a dose of 3 mg/kg …