Guttate psoriasis induced by infliximab in a child with Crohn's disease

Management of Guttate Psoriasis: A Systematic Review

Guttate psoriasis (GP) is a variant of psoriasis characterized by scattered "drop-like" papules and plaques, accounting for up to a quarter of psoriasis cases. Although GP can clear within 3 to 4 months, up to 39% of cases may progress to chronic plaque psoriasis. Currently, there is a paucity of literature investigating the efficacy of different treatment modalities. This systematic review aims to synthesize all available data on GP treatment efficacy. A literature search was conducted using Medline, Embase, Web of Science, and CINAHL with no date limits. A total of 75 studies satisfied eligibility criteria and were analyzed. Most studies were case reports, series, or retrospective studies. Only 5 randomized controlled trials (RCTs) were identified. For topical treatments, corticosteroids and calcipotriol creams had the most evidence for efficacy. Four categories of systemic therapies were identified: traditional immunosuppressants, antibiotics, retinoids, and biologics. Evidence regarding antibiotic therapy suggests minimal connection between underlying infection resolution and GP lesion remission. Phototherapy had the most robust evidence, with narrowband ultraviolet B (UVB) being the most effective. Our findings are limited by high heterogeneity in study design and high risk of bias. Based on our review, we propose the following treatment algorithm. As first-line therapy, we recommend topical corticosteroids and calcipotriol cream, in combination with phototherapy. As supportive therapy, we recommend antibiotics if applicable. For second-line therapy, we recommend methotrexate or cyclosporine. For severe and refractory GP, biologics can be used as third-line treatment. RCTs are needed to provide higher quality evidence to create standardized treatment recommendations.

Childhood guttate psoriasis: an updated review

Background

Guttate psoriasis is common and affects 0.5-2% of individuals in the paediatric age group. This review aims to familiarize physicians with the clinical manifestations, evaluation, diagnosis and proper management of guttate psoriasis.

Methods

A search was conducted in July 2023 in PubMed Clinical Queries using the key term "guttate psoriasis". The search strategy included all observational studies, clinical trials and reviews published within the past 10 years. The information retrieved from the search was used in the compilation of the present article.

Results

Guttate psoriasis typically presents with an abrupt onset of numerous, small, scattered, tear-drop-shaped, scaly, erythematous, pruritic papules and plaques. Sites of predilection include the trunk and proximal extremities. There may be a history of preceding streptococcal infection. Koebner phenomenon is characteristic. Guttate psoriasis may spontaneously remit within 3-4 months with no residual scarring, may intermittently recur and, in 40-50% of cases, may persist and progress to chronic plaque psoriasis. Given the possibility for spontaneous remission within several months, active treatment may not be necessary except for cosmetic purposes or because of pruritus. On the other hand, given the high rates of persistence of guttate psoriasis and progression to chronic plaque psoriasis, some authors suggest active treatment of this condition.

Conclusion

Various treatment options are available for guttate psoriasis. Triggering and exacerbating factors should be avoided if possible. Topical corticosteroids alone or in combination with other topical agents (e.g. tazarotene and vitamin D analogues) are the most rapid and efficient treatment for guttate psoriasis and are therefore the first-line treatment for mild cases. Other topical therapies include vitamin D analogues, calcineurin inhibitors, anthralin, coal tar and tazarotene. Ultraviolet phototherapy is the first-line therapy for moderate-to-severe guttate psoriasis, as it is more practical than topical therapy when treating widespread or numerous small lesions. Systemic immunosuppressive and immunomodulatory therapies (e.g. methotrexate, cyclosporine, retinoids, fumaric acid esters and biologics) may be considered for patients with moderate-to-severe guttate psoriasis who fail to respond to phototherapy and topical therapies.

Psoriasis Associated With Tumor Necrosis Factor Inhibitors in Children With Inflammatory Diseases

OBJECTIVE

To estimate the incidence rate (IR) of psoriasis in children with inflammatory bowel disease (IBD), juvenile idiopathic arthritis (JIA), and chronic noninfectious osteomyelitis (CNO) with tumor necrosis factor inhibitor (TNFi) exposure as compared to children without TNFi exposure and to the general pediatric population.

METHODS

This was a single-center retrospective cohort study of children with IBD, JIA, or CNO from 2008 to 2018. TNFi exposure was defined as a prescription for adalimumab, etanercept, infliximab, certolizumab, or golimumab, and the primary outcome was incident psoriasis. IRs and standardized incidence ratios (SIRs) were calculated. Cox proportional hazards models were used to assess the association of psoriasis with TNFi exposure and other risk factors.

RESULTS

Of the 4,111 children who met inclusion criteria, 1,614 (39%) had TNFi exposure and 2,497 (61%) did not, with 4,705 and 6,604 person-years of follow-up, respectively. There were 58 cases (IR 12.3 per 1,000 person-years) and 25 cases (IR 3.8 per 1,000 person-years) of psoriasis in children with and without TNFi exposure, respectively. The SIR was 18 (95% confidence interval [95% CI] 15-22) overall, 30 (95% CI 23-39) for children with TNFi exposure, and 9.3 (95% CI 6.3-14) for children without TNFi exposure. The hazard ratio of psoriasis comparing TNFi exposure to no TNFi exposure was 3.84 (95% CI 2.28-6.47; P < 0.001).

CONCLUSION

Children with IBD, JIA, and CNO had an increased rate of psoriasis compared to the general pediatric population, with the highest rate in those with TNFi exposure.

Paradoxical Psoriasis Induced by Anti-TNFα Treatment: Evaluation of Disease-Specific Clinical and Genetic Markers

Paradoxical psoriasis (PP) may occur during treatment with anti-tumor necrosis factor-alpha (TNF-α) drugs in various chronic immune-mediated diseases, mainly inflammatory bowel diseases (IBD) and psoriasis. In this study, clinical and genetic characteristics of PP arising in IBD and psoriatic patients were investigated to identify disease-specific markers of the paradoxical effect. A total of 161 IBD and psoriatic patients treated with anti-TNF-α drugs were included in the study. Of these patients, 39 developed PP. All patients were characterized for the main clinical–pathologic characteristics and genotyped for six candidate single nucleotide polymorphisms (SNPs) selected for their possible role in PP susceptibility. In IBD patients, the onset of PP was associated with female sex, presence of comorbidities, and use of adalimumab. IBD patients with PP had a higher frequency of the TNF-α rs1799964 rare allele (p = 0.006) compared with cases without the paradoxical effect, and a lower frequency of the human leucocyte antigen (HLA)-Cw06 rs10484554 rare allele (p = 0.03) compared with psoriatic patients with PP. Overall, these findings point to specific clinical and genetic characteristics of IBD patients with PP and provide data showing that genetic variability may be related to the paradoxical effect of anti-TNF-α drugs with possible implications into clinical practice.

Tumor necrosis factor-α inhibitor-induced psoriasis in juvenile idiopathic arthritis patients

BACKGROUND/OBJECTIVES

The development of psoriasis while on tumor necrosis factor inhibitors (TNFi) is a paradoxical effect of agents that treat psoriasis. There is a paucity of data available on this entity in juvenile idiopathic arthritis (JIA). Our objectives were to determine the prevalence of TNFi-induced psoriasis in patients with JIA at two pediatric centers, and psoriasis response to therapeutic modifications.

METHODS

We performed retrospective chart review on patients with JIA treated with TNFi (adalimumab, etanercept, infliximab) who developed psoriasis. TNFi-induced psoriasis was defined as an incident diagnosis of psoriasis after starting a TNFi. Patients with personal histories of psoriasis prior to TNFi therapy were excluded. Following diagnosis, responses to medication changes were defined based on physician assessments.

RESULTS

Nine of 166 (5.4%) patients on TNFi for JIA were diagnosed with TNFi-induced psoriasis. All cases were female. One had a family history of psoriasis. The median age was 10 (range 2-16) years. Five (55%) patients experienced scalp psoriasis, including four (44%) with alopecia. Two (22%) patients achieved significant improvement after switching to different classes of biologic agents, while three (33%) patients had significant improvement following discontinuation of biologic therapy. One of five patients who switched to a different TNFi had complete resolution, while four had worsening symptoms or partial improvement.

CONCLUSIONS

Our findings demonstrate the prevalence of TNFi-induced psoriasis in JIA at two centers. Though larger studies are needed, our data suggest discontinuation of TNFi or biologic class switching should be considered as treatment strategies in select patients.

Anti-Tumor Necrosis Factor α-Related Psoriatic Lesions in Children with Inflammatory Bowel Disease: Case Report and Systematic Literature Review

We report a child with Crohn's disease and infliximab-induced guttate psoriasis. We also performed a systematic literature review on this intriguing paradoxical phenomenon in children with inflammatory bowel disease.

Biologic response modifiers and pediatric psoriasis

The efficacy and safety of biologic response modifiers such as etanercept, adalimumab, infliximab, and ustekinumab have been demonstrated in the treatment of psoriasis in adults, but none are currently approved for the treatment of psoriasis in children in the United States, and only etanercept is approved for the treatment of psoriasis in children in the European Union. Through case reports, case series, and a large clinical trial of the use of etanercept, the literature supports the use of these agents to treat psoriasis in children. Data on the use of the tumor necrosis factor-α antagonists etanercept, adalimumab, and infliximab in the treatment of other inflammatory diseases in children-namely Crohn's disease, juvenile arthritis, and uveitis--support their safety profile in children.

Multitarget fatty acid amide hydrolase/cyclooxygenase blockade suppresses intestinal inflammation and protects against nonsteroidal anti-inflammatory drug-dependent gastrointestinal damage

The ability of nonsteroidal anti-inflammatory drugs (NSAIDs) to inhibit cyclooxygenase (Cox)-1 and Cox-2 underlies the therapeutic efficacy of these drugs, as well as their propensity to damage the gastrointestinal (GI) epithelium. This toxic action greatly limits the use of NSAIDs in inflammatory bowel disease (IBD) and other chronic pathologies. Fatty acid amide hydrolase (FAAH) degrades the endocannabinoid anandamide, which attenuates inflammation and promotes GI healing. Here, we describe the first class of systemically active agents that simultaneously inhibit FAAH, Cox-1, and Cox-2 with high potency and selectivity. The class prototype 4: (ARN2508) is potent at inhibiting FAAH, Cox-1, and Cox-2 (median inhibitory concentration: FAAH, 0.031 ± 0.002 µM; Cox-1, 0.012 ± 0.002 µM; and Cox-2, 0.43 ± 0.025 µM) but does not significantly interact with a panel of >100 off targets. After oral administration in mice, ARN2508 engages its intended targets and exerts profound therapeutic effects in models of intestinal inflammation. Unlike NSAIDs, ARN2508 causes no gastric damage and indeed protects the GI from NSAID-induced damage through a mechanism that requires FAAH inhibition. Multitarget FAAH/Cox blockade may provide a transformative approach to IBD and other pathologies in which FAAH and Cox are overactive.

Skin reactions during anti-TNFα therapy for pediatric inflammatory bowel disease: a 2-year prospective study

BACKGROUND

Although the development of therapy-related skin reactions is common along with an increase in the number of adult patients receiving anti-TNFα, there are few studies on pediatric inflammatory bowel disease; hence, this prospective study focuses on skin reactions related to infliximab therapy.

METHODS

All pediatric patients with inflammatory bowel disease undergoing infliximab therapy were prospectively screened for the presence of skin manifestations at the time of each infusion between March 1, 2011 and March 31, 2011 at Children's Hospital, Helsinki, Finland. Blood inflammatory markers and fecal calprotectin levels were measured at the time of infusions.

RESULTS

During the study period, 84 children with inflammatory bowel disease (Crohn's n = 64) received infliximab infusions (the median duration of therapy 12.2 mo). Almost every other patient (n = 40; 47.6%) presented chronic skin reactions, 23% with lesions considered severe. Most commonly, the patient's ear lobes and scalp were affected with psoriasis-like manifestations, followed by their eyelids, perioral and pubic area, trunk, and the extremities. However, an HLA-Cw*0602 genotype associating with psoriasis was rare. Interestingly, most patients with skin reactions had a low degree of intestinal inflammation based on their fecal calprotectin levels (median level, 133 μg/g versus 589 in unaffected patients; P < 0.016). Seven patients (8.3% of all patients but 17% of those with skin lesions) discontinued the given therapy due to a skin reaction.

CONCLUSIONS

Skin reactions are common during maintenance therapy with infliximab in pediatric patients. For most patients, skin reactions seem to correlate with a low level of intestinal inflammation. Although potentially harsh, skin lesions mostly allow continuation of infliximab.

Clinical management of paradoxical psoriasiform reactions during TNF- α therapy

There have been reports of paradoxical induction or worsening of psoriasis during treatment with tumor necrosis factor (TNF) α agents (infliximab, etanercept, adalimumab, and certolizumab). It has been hypothesized that an imbalance between TNF-α and interferon α might have a role in the etiology and pathogenesis of these reactions. Paradoxical psoriasiform reactions can be divided clinically into de novo psoriasis and exacerbation of preexisting psoriasis. The first, which is more common and more extensively described in the literature, occurs in patients without a history of psoriasis who are receiving TNF-α therapy for another inflammatory disorder. The second can occur with or without changes in the morphology of the lesions. In this article, we review the literature on the clinical and histologic features of paradoxical psoriasiform reactions, analyze their clinical course and treatment, and propose a clinical management model for use in routine practice.

Induction or exacerbation of psoriatic lesions during anti-TNF-α therapy for inflammatory bowel disease: a systematic literature review based on 222 cases

BACKGROUND

Paradoxical cases of psoriatic lesions induced or exacerbated by anti-tumor necrosis factor (TNF)-α therapy have been reported more frequently in recent years, but data related to inflammatory bowel disease (IBD) are rare. A systematic literature review was performed to provide information about this adverse effect in patients with IBD who receive anti-TNF therapy.

METHODS

Published studies were identified by a search of Medline, Embase, Cochrane, SciELO, and LILACS databases.

RESULTS

A total of 47 studies (222 patients) fulfilled the inclusion criteria and were selected for analysis. Clinical and therapeutic aspects varied considerably among these reports. Of the 222 patients, 78.38% were diagnosed with Crohn's disease, and 48.20% were female. The mean patient age was 26.50 years, and 70.72% of patients had no history of psoriasis. Patients developed psoriasiform lesions (55.86%) more often than other types of psoriatic lesions, and infliximab was the anti-TNF-α therapy that caused the cutaneous reaction in most patients (69.37%). Complete remission of cutaneous lesions was observed in 63.96% of the cases.

CONCLUSIONS

We found that psoriatic lesions occurred predominantly in adult patients with Crohn's disease who received infliximab and had no previous history of psoriasis. Most patients can be managed conservatively without discontinuing anti-TNF-α therapy.

Infliximab-induced psoriasis and psoriasiform skin lesions in pediatric Crohn disease and a potential association with IL-23 receptor polymorphisms

BACKGROUND

Infliximab (IFX), an established therapy for pediatric Crohn disease (CD), is also efficacious in treating psoriasis, a skin disorder, in which tumor necrosis factor-α is implicated pathogenically. Paradoxically, there have been numerous reports of new-onset psoriasis following tumor necrosis factor-α antagonist therapy in adult patients with inflammatory bowel disease, but pediatric data are sparse.

METHODS

A retrospective review of all IFX-treated patients with CD, who subsequently developed psoriasis, at a single pediatric inflammatory bowel disease center, was performed. A subset of affected patients (10/18) and CD controls (147 of 172) treated with IFX but without the development of psoriasis were genotyped for polymorphisms in the interleukin-23 receptor (IL-23R) gene, which has been identified as conferring susceptibility to both CD and psoriasis.

RESULTS

Eighteen (10.5%) of 172 IFX-treated patients with CD developed new-onset psoriasis (n = 17) or worsening of existing psoriasis (n = 1). The duration of IFX exposure was variable, ranging from 1 to 25 infusions. Three patients discontinued IFX because of this complication. Most patients responded well to topical steroid therapy. In comparison to disease-matched controls, patients with CD developing psoriasis following IFX therapy were more likely to be homozygous for specific polymorphisms in the IL-23R gene (rs10489628, rs10789229, and rs1343151).

CONCLUSIONS

As in adults, the development of psoriasis or psoriasiform skin lesions occurs in pediatric patients with CD treated with IFX. Adequately powered studies are required to further explore the preliminary findings reported here to determine whether polymorphisms in the IL-23R gene have a role in the pathogenesis of this paradoxical process, which presently remains unexplained.

Onset of psoriasis in patients with inflammatory bowel disease treated with anti-TNF agents

Anti-TNF agents are widely used in the treatment of some inflammatory diseases, such as inflammatory bowel disease and psoriasis. Their use has led to a significant advance in the treatment of these diseases. Paradoxically, the onset of psoriatic lesions has been observed in patients on anti-TNF treatment. The cause of this side effect has not yet been clearly identified. In recent years, an increasing number of cases of psoriasis related to anti-TNF therapy in inflammatory bowel disease patients have been reported. Although withdrawal of anti-TNF was usually implemented in the first reports, in more recent series the maintenance of the drug with topical therapy, with the exception of the most severe or extensive forms of skin lesions, appears to be the treatment of choice. This article summarizes the relevant literature, discusses the etiopathology, epidemiology, location and phenotypes of psoriatic lesions and the management of this side effect.

Paradoxical inflammation induced by anti-TNF agents in patients with IBD

Anti-TNF antibodies have acquired a prominent place in the management of IBD (including Crohn's disease and ulcerative colitis), rheumatologic conditions (such as rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis) and psoriasis. They have a good safety profile, especially when contraindications such as demyelinating disease, active infections and/or abscesses are ruled out, and when necessary precautions to prevent reactivation of tuberculosis are taken. However, with increasing use of these agents, paradoxical adverse events have been reported. Some of these features are shared with the underlying disease for which these drugs are given, making management of these conditions challenging. For example, anti-TNF therapy is used for the treatment of psoriasis, but psoriasiform lesions are sometimes observed in patients receiving therapy. Similarly, anti-TNF therapy is used for the treatment of rheumatologic diseases, but arthralgias and arthritis are sometimes observed in patients receiving anti-TNF agents. We review the paradoxical inflammation induced by anti-TNF agents in patients with IBD, provide hypotheses for the occurrence of this paradoxical inflammation and give practical advice on how to manage these patients.

Infliximab-induced psoriasis during therapy for Crohn's disease

Although therapy with tumor necrosis factor-alpha inhibitors (anti-TNF) provides beneficial effects in different immune inflammatory disorders, paradoxical cases of anti-TNF-induced psoriasis have increasingly been reported, mostly in the setting of rheumatologic diseases. To date, less than 50 cases of infliximab-induced psoriasis in inflammatory bowel disease patients have been described. The present report was aimed at describing two new cases of infliximab-induced psoriasis during therapy for Crohn's disease and at carrying out a review on this intriguing phenomenon.

Induction of psoriasis with anti-TNF agents in patients with inflammatory bowel disease: a report of 21 cases

AIM

Anti-tumor necrosis factor (TNF)-alpha agents are widely used for the treatment of both inflammatory bowel disease (IBD) and psoriasis. Psoriatic skin lesions induced by anti-TNF have been described in patients with IBD. We report a case series of psoriasis induced by anti-TNF agents in IBD patients.

METHODS

Systematic analysis of cases of psoriasis induced by anti-TNF in an IBD patient cohort in tertiary hospitals of Madrid.

RESULTS

A total of 21 of 1294 patients with IBD treated with anti-TNF-alpha agents developed drug-induced psoriasis (cumulative incidence 1.62%; 95% CI 1.06%-2.47%): 14 patients with infliximab and 7 with adalimumab; seventeen with Crohn's disease, 4 with ulcerative colitis. The onset of skin lesions varied in a wide range of time (after a mean 13±8 doses). The most frequent site of skin lesions was the limbs (62%) followed by the trunk (48%) and the scalp (43%). The psoriasis phenotypes were plaque psoriasis (57%), scalp (14%), palmoplantar pustulosis (14%), pustular generalized psoriasis (5%), guttate (5%) and inverse (5%). Four patients interrupted the anti-TNF treatment, and that led to the complete regression of lesions in 1 of them. The other 17 patients were maintained on anti-TNF therapy and managed with topical steroids.

CONCLUSION

Psoriatic lesions can be induced by anti-TNF drugs. Plaque psoriasis on the extremities and trunk were the most frequent presentations in our series. Topical steroid treatment is effective in most patients. Anti-TNF discontinuance may be reserved for patients with severe psoriasis or patients without response to topical therapy.

The onset of psoriasis during the treatment of inflammatory bowel diseases with infliximab: should biological therapy be suspended?

CONTEXT

Several paradoxical cases of infliximab-induced or-exacerbated psoriatic lesions have been described in the recent years. There is disagreement regarding the need to discontinue infliximab in order to achieve the resolution of these adverse cutaneous reactions specifically in inflammatory bowel disease (IBD) patients.

OBJECTIVE

To systematically review the literature to collect information on IBD patients that showed this adverse cutaneous reaction, focusing mainly on the therapeutic approach.

METHODS

A systematic literature review was performed utilizing Medline, Embase, SciELO and Lilacs databases. Published studies were identified, reviewed and the data were extracted.

RESULTS

Thirty-four studies (69 IBD patients) met inclusion criteria for review. There was inconsistency in reporting of some clinical and therapeutic aspects. Most patients included had Crohn's disease (89.86%), was female (47.83%), had an average age of 27.11 years, and no reported history of psoriasis (84.05%). The patients developed primarily plaque-type psoriasis (40.58%). There was complete remission of psoriatic lesions in 86.96% of IBD patients, existing differences in the therapeutic approaches; cessation of infliximab therapy led to resolution in 47.83% of cases and 43.48% of patients were able to continue infliximab therapy.

CONCLUSION

As increasing numbers of IBD patients with psoriasis induced or exacerbated by infliximab, physicians should be aware of its clinical manifestations so that appropriate diagnosis and treatment are properly established. The decision whether to continue or discontinue infliximab should be individualized.

Tumour necrosis factor (TNF)-blocking agents in juvenile psoriatic arthritis: are they effective?

OBJECTIVES

To evaluate the effectiveness of tumour necrosis factor (TNF) blockers in juvenile psoriatic arthritis (JPsA).

METHODS

The study was a prospective ongoing multicentre, observational study of all Dutch juvenile idiopathic arthritis (JIA) patients using biologicals. The response of arthritis was assessed by American College of Rheumatology (ACR) paediatric response and Wallace inactive disease criteria. The response of psoriatic skin lesions was scored by a 5-point scale.

RESULTS

Eighteen JPsA patients (72% female, median age onset 11.1 (range 3.3-14.6) years, 50% psoriatic skin lesions, 39% nail pitting, 22% dactylitis) were studied. The median follow-up time since starting anti-TNFα was 26 (range 3-62) months. Seventeen patients started on etanercept and one started on adalimumab. After 3 months of treatment 83% of the patients achieved ACR30 response, increasing to 100% after 15 months. Inactive disease reached in 67% after 39 months. There was no discontinuation because of inefficacy. Six patients discontinued treatment after a good clinical response. However, five patients flared and restarted treatment, all with a good response. During treatment four patients (two JPsA and two JIA patients with other subtypes) developed de novo psoriasis. In four of the nine patients the pre-existing psoriatic skin lesions improved.

CONCLUSION

Anti-TNFα therapy in JPsA seems effective in treating arthritis. However, in most patients the arthritis flared up after treatment discontinuation, emphasising the need to investigate optimal therapy duration. The psoriatic skin lesions did not respond well and four patients developed de novo psoriasis.

Anti-TNF-α agents in the treatment of immune-mediated inflammatory diseases: mechanisms of action and pitfalls

TNF-α is a potent inducer of the inflammatory response, a key regulator of innate immunity and plays an important role in the regulation of Th1 immune responses against intracellular bacteria and certain viral infections. However, dysregulated TNF can also contribute to numerous pathological situations. These include immune-mediated inflammatory diseases (IMIDs) including rheumatoid arthritis, Crohn’s disease, psoriatic arthritis, ankylosing spondylitis, ulcerative colitis and severe chronic plaque psoriasis. Animal and human studies concerning the role of TNF-α in IMIDs have led to the development of a therapy based on TNF blockage. This article focuses first on the potential mechanisms by which the three currently licensed agents, adalimumab, etarnecept and infliximab, decrease the inflammatory activity of patients with different IMIDs. Second, it focuses on the risks, precautions and complications of the use of TNF-α inhibitors in these patients.

Psoriatic skin lesions induced by tumor necrosis factor antagonist therapy: clinical features and possible immunopathogenesis

OBJECTIVE

The induction or exacerbation of psoriasis in patients treated with tumor necrosis factor (TNF) antagonists is a well-established phenomenon. The goals of this comprehensive literature analysis were to update currently available data regarding this adverse event, to identify any clinical patterns in the cohort of reported patients, and to review the possible immunopathogenesis.

METHODS

A systematic literature review was performed utilizing PubMed and Medline databases (1996 to August 2009) searching the index terms "tumor necrosis factor alpha inhibitor," "TNF," "infliximab," "etanercept," "adalimumab," combined with the terms "psoriasis," "pustular," "skin," "rash," "palmoplantar," and "paradoxical." All relevant articles were reviewed. Patients who did not appear to meet accepted classification criteria for their treated disease, who had a more probable explanation or other likely diagnosis for their skin findings or known possible triggering factor for the skin eruption, including infection, were excluded from this analysis.

RESULTS

Two hundred seven cases met inclusion criteria for review. Of these, 43% were diagnosed with rheumatoid arthritis, 26% with seronegative spondyloarthropathy, and 20% with inflammatory bowel disease. Mean patient age was 45 years and 65% were female. Fifty-nine percent were being treated with infliximab, 22% with adalimumab, and 19% with etanercept. Lesion morphology included pustular psoriasis in 56%, plaque psoriasis in 50%, and guttate lesions in 12%; 15% experienced lesions of more than 1 type. No statistically significant predisposing factors for the development of new-onset psoriasis were found. Sixty-six percent of patients were able to continue TNF antagonist therapy with psoriasis treatments. The pathogenesis appears to involve disruption of the cytokine milieu with production of unopposed interferon-α production by plasmacytoid dendritic cells in genetically predisposed individuals. Genetic polymorphisms may play a role in this paradoxical reaction to TNF blockade.

CONCLUSIONS

TNF antagonist induced psoriasis is a well-described adverse event without any known predisposing risk factors. Most patients can be managed conservatively without drug withdrawal. Registry data reporting is necessary to define the true incidence and prevalence of this condition. Genomic studies of affected patients may assist with identification of predisposed patients and elucidation of the molecular trigger of this perplexing response.

Rash induced by anti-tumor necrosis factor agents in an adolescent with Crohn's disease

BACKGROUND

A 17-year-old white male with Crohn's disease who was receiving maintenance infusions of the anti-tumor necrosis factor (TNF) agent, infliximab, presented with a new-onset psoriasiform skin rash. The rash was not responsive to topical or oral corticosteroids and worsened after infliximab infusions and after subsequent administration of a second anti-TNF drug, adalimumab.

INVESTIGATIONS

Full medical history and physical examination, including assessment of the morphology of rash and the temporal correlation with administration of anti-TNF agents.

DIAGNOSIS

Anti-TNF-agent induced psoriasiform skin rash.

MANAGEMENT

Discontinuation of anti-TNF therapy. The patient opted to have his gastrointestinal symptoms treated with oral mesalazine and metronidazole.