Infliximab-induced acne: report of two cases

A Rare Case of Nontraumatic Thoracic Compression Fracture in a 28-Year-Old Man

ABSTRACT

A 28-yr-old African American man with a history of synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome, tobacco use, and sickle cell trait was referred to a physiatrist at a multidisciplinary spine center with a 1-yr history of nontraumatic thoracic back pain that had significantly worsened over the previous 4 wks. In the context of recurrent infections requiring hospital admissions and the patient's immunosuppressed status, magnetic resonance imaging of his thoracic spine was obtained, showing an acute or subacute anterior compression deformity of the T7 vertebral body. He was subsequently provided with a hyperextension brace, physical therapy referral, and a trial of intranasal calcitonin. The patient reported significant improvement in pain at his 3-mo follow-up appointment and continued to show pain and functional improvement in physical therapy sessions up to 6 mos later.

Dermatological complications of therapy with biologics in inflammatory autoimmune diseases

BACKGROUND AND OBJECTIVE

Cutaneous adverse events (CAEs) occur in up to 10 % of patients with immune-mediated inflammatory disease (IMID) treated with antitumor necrosis factor (TNF)α agents. The aim of this clinical study was to track and observe the course of CAEs in all biologic therapies.

PATIENTS AND METHODS

The population for this study consisted of patients with CAEs under biologic therapy who were examined by experienced board-certified dermatologists in the outpatient department of the University Hospital Essen, Department of Dermatology.

RESULTS

Altogether 39 patients with a total of 45 CAEs were included in this study. In 60 % of the cases a form of paradoxical psoriasis was diagnosed. Two thirds (66.6 %) of the patients with CAEs were diagnosed with an underlying inflammatory bowel disease (IBD). TNFα antagonists were the triggering agents in about 95 % of the cases. Changes in biological therapy were required in nearly half of the cases (46.2 %). Almost 90 % of the patients had either a complete (42.1 %) or a partial response (47 %).

CONCLUSIONS

Management of CEAs under biological therapy can be challenging in clinical practice. Case discussions between gastroenterologists, rheumatologists and dermatologists should be undertaken to best manage patients with CAEs and avoid unnecessary changes of therapy.

Review and Management of Acneiform Eruptions in Patients with Immune Disorders

Immune disorders are associated with acne or acneiform lesions secondary to the occurrence of acne vulgaris or acneiform eruptions arising as a result of immunosuppressive medication or infection. In this review, we aim to provide an overview of acne and acneiform eruptions that can arise in the immunosuppressed host. Tips for differentiating between various acneiform entities are discussed, as well as a brief overview of treatment considerations.

Review article: dermatological complications of immunosuppressive and anti-TNF therapy in inflammatory bowel disease

BACKGROUND

With the expanding list of medications available to treat patients with inflammatory bowel disease (IBD), it is important to recognise adverse events, including those involving the skin. Dermatological adverse events may be confused with extra-intestinal manifestations of IBD.

AIM

To review drug-related dermatological manifestations associated with immunosuppressive and anti-tumour necrosis factor (anti-TNF) therapy.

METHODS

The literature was searched on PubMed for dermatological adverse events in IBD.

RESULTS

Present thiopurine exposure was associated with a 5.9-fold [95% confidence interval (CI), 2.1-16.4] increased risk of developing non-melanoma skin cancer (NMSC). The peak incidence is highest in Caucasians over the age of 65 years with crude incidence rates of 4.0 and 5.7/1000 patient-years for present and previous use. In anti-TNF-exposed subjects, drug-induced lupus was reported in 1% of the cases and a psoriatic rash in up to 3% of the cases. Anti-TNF monotherapy increases the risk of NMSC ~2-fold to a rate of 0.5 cases per 1000 person-years. Cutaneous lymphomas have been rarely reported in subjects on thiopurine or anti-TNF drug monotherapy. Combination therapy seems to have an additive effect on the risk of developing NMSC and lymphoma.

CONCLUSIONS

Physicians need to be aware of the wide spectrum of dermatological complications of immunosuppressive and anti-TNF therapy in IBD, especially psoriasis and non-melanoma skin cancer. Vigilance and regular screening for non-melanoma skin cancer is recommended. Case discussions between gastroenterologists and dermatologists should be undertaken to best manage dermatological adverse events.

Long-term treatment of severe SAPHO syndrome with adalimumab: case report and a review of the literature

SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) syndrome defines an association of inflammatory cutaneous disorders with osteoarticular manifestations and represents a clinical and therapeutic challenge. We report a case of severe SAPHO syndrome with acne conglobata and a diffuse involvement of the anterior chest wall and sacroiliac joints that required treatment with isotretinoin and adalimumab, a new fully human anti-tumor necrosis factor (TNF)-α monoclonal antibody. Combination treatment determined a complete clinical remission of cutaneous and osteoarticular manifestations after 48 weeks. Despite maintenance of clinical remission, follow-up imaging studies after 24 months of adalimumab monotherapy revealed osteoarticular disease progression, with features of inflammatory osteitis. TNFα antagonists have been used as third-line therapy for SAPHO syndrome in single case reports or case series, but these lack consistent long-term follow-up. SAPHO syndrome can present an intermittent-favorable course in the majority of cases as well as a chronic-progressive course, the latter requiring aggressive combination treatment with TNFα antagonists and conventional systemic agents.

Drug-induced acneiform eruption

Drug-induced acne is a specific subset of acne that usually has some specific features, namely a monomorphic pattern, an unusual location of the lesions beyond the seborrheic areas, an unusual age of onset, a resistance to conventional acne therapy and, of course, the notion of a recent drug introduction. Many drugs can be responsible for such a clinical pattern. Corticosteroids, neuropsychotherapeutic drugs, antituberculosis drugs, and immunomodulating molecules are the more classical drugs associated with induced acne. Recently, new drugs, mainly targeted therapy in the field of oncology, such as epidermal growth factor receptor inhibitors, have been associated with an increased frequency of this adverse effect. Disruption of the culprit drug is rarely mandatory in cases of drug-induced acne. Close cooperation between the dermatologist and medical staff in charge of the patient is an important challenge to achieve optimal management of the initial disease.

Adaptive immune responses in primary cutaneous sarcoidosis

Sarcoidosis is a multisystemic inflammatory disorder with cutaneous lesions present in about one-quarter of the patients. Cutaneous lesions have been classified as specific and nonspecific, depending on the presence of nonnecrotizing epithelial cell granulomas on histologic studies. The development and progression of specific cutaneous sarcoidosis involves a complex interaction between cells of the adaptive immune systems, notably T-lymphocytes and dendritic cells. In this paper, we will discuss the role of T-cells and skin dendritic cells in the development of primary cutaneous sarcoidosis and comment on the potential antigenic stimuli that may account for the development of the immunological response. We will further explore the contributions of selected cytokines to the immunopathological process. The knowledge of the adaptive immunological mechanisms operative in cutaneous sarcoidosis may subsequently be useful for identifying prevention and treatment strategies of systemic sarcoidosis.

[What's new in clinical dermatology?]

For this What's new in clinical dermatology?, I have selected some important publications mainly in the field of the infectious dermatosis and drugs allergy. The Chikungunya virus which is responsible of several epidemics since 2005 seems to be a virus with a cutaneous tropism. Sexually transmitted diseases are still a public health problem and we shall review the situation for syphilis, lymphogranuloma venereum and the new dynamic profile of HIV in France. Lyme disease has been the subject of consensus conference in France and in the United States. Original clinical presentations in relation with infectious agent will be also presented. We shall give a large place to what I call the toxidermatology. During the year 2007, the role of gadolinium in the nephrogenic systemic fibrosis has been confirmed, many publications have reported the side effects of biotherapies on the skin and we shall emphasize the paradoxical of some of them. Hypersensitivity syndrome and notably the controversial role of viral reactivations has been reported. The relationship between psoriasis and metabolic syndrome or cardiovascular risks has been discussed since 2006. New clinical features have been described and will be presented during this session.