The optimum treatment for metastatic EP is not standardized, and the results obtained to date were generally poor. In this context, we consider it of interest to highlight the response of our patient to the therapeutic regime employed, which may be advantageous in future cases of this rare tumor.

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A total of 48 patients were included in the study. At the end of the study period, 35.41% (17/48) of our patients remained on apremilast, with treatment durations ranging 130-627 days compared with 50.6% in the Lee et al study. The patients who stopped taking apremilast (64.58%, 31/48) had treatment failures after an average of 169 days and a median of 144 days. No patient was lost to follow-up. Mean drug survival duration was 313 (95% confidence interval 247-378) days (Fig 1); and median drug survival was 200 days (Fig 2). With the same criteria, the result of this analysis shows a higher discontinuation rate compared with Lee et al's study. Fougerousse et al described a discontinuation of 44% and Cattan et al 47% on the 12th week. 2,3 Although Lee et al showed similar persistence rates among patients who had and had not tried other systemic therapies, we think that the striking differences between their results and ours could be attributed to the fact that in our series only 4 patients were naive for systemic treatments. Hence, having received previous systemic treatments might have affected results. In our study, thirty-one patients had been treated with $2 previous systemic treatments and 11 with $1 biologic treatment. As stated by Ighani et al, this fact implies that patients in real-world practices have more challenging psoriasis than those in randomized controlled trials. 4 Despite the limitations of our study, the results of the 3 studies using patients from world-real practices are concordant and strongly suggest the need to place psoriasis treatment trials at proper sites in future studies.

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