Lichenoid reaction induced by adalimumab

Chemotherapy-induced zosteriform lichen planus following mastectomy: A rare case report

INTRODUCTION

Zosteriform Lichen Planus represents a relatively uncommon variant of LP. It is characterized by a distinctive distribution following Blaschko's line and involving multiple dermatomes, setting it apart as a unique manifestation. There have been several cases of cutaneous LP reported, but relatively few of them presented as zosteriform LP. To our knowledge, this is the first documented case of zosteriform LP as an adverse drug reaction.

PRESENTATION OF CASE

A 62-year-old female presented to the dermatology clinic with asymptomatic hyperpigmented patches that exhibited gradual spreading. The patient had a history of breast cancer and underwent a mastectomy procedure, chemotherapy, adjuvant therapy, and radiation treatment. A dermatological examination revealed the presence of multiple hyperpigmented, ill-defined macules arranged linearly on the left flank and inner thigh.

DISCUSSION

A biopsy confirmed the diagnosis as Lichen Planus. The patient's condition significantly improved following a nine-week topical steroid with dose tapering.

CONCLUSION

Zosteriform LP is a rare adverse skin reaction associated with chemotherapeutic drugs. The immunosuppression induced by chemotherapy may trigger T-cell activation, leading to a lichenoid tissue reaction. A thorough patient history assessment is essential for the management of such adverse reactions.

Metabolic, pharmacokinetic, and toxicological issues of biologic therapies currently used in the treatment of hidradenitis suppurativa

INTRODUCTION

Hidradenitis suppurativa is a chronic, relapsing, debilitating inflammatory dermatologic disease of the terminal hair follicles at intertriginous sites clinically characterized by painful inflammatory nodules, abscesses, draining sinus tracts, and dermal fibrosis. The management of hidradenitis suppurativa is a challenge and usually consists of both medical and surgical approaches, which must often be combined for best outcome. The introduction of biological therapies, specifically TNFα-inhibitors such as adalimumab, has profoundly changed the therapeutic armamentarium of the disease.

AREAS COVERED

The PubMed database was searched using combinations of the following keywords: hidradentis suppurativa, biologic therapy, TNF-α inhibitors, adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, adverse effects, pharmacodynamics, pharmacology, adverse events, pharmacokinetics, drug interaction. This article reviews and updates the chemistry, pharmacokinetics, mechanism of action, adverse effects, drug interactions of on-label and off-label use of TNF-α inhibitors in HS.

EXPERT OPINION

Biologic agents, particularly adalimumab, exhibit clinical efficacy in patients with hidradenitis suppurativa. Careful patient selection and close monitoring during treatment are mandatory to provide safe and effective use of the TNF-α inhibitor. Familiarity with biologic agents is crucial because these agents could become a consolidated treatment option in the clinician's therapeutic approaches.

A review and guide to drug-associated oral adverse effects-Oral mucosal and lichenoid reactions. Part 2

Dental practitioners and other health professionals commonly encounter and manage adverse medicine effects that manifest in the orofacial region. Numerous medicines are associated with a variety of oral adverse effects. However, due to lack of awareness and training, these side effects are not always associated with medicine use and are underreported to pharmacovigilance agencies by dentists and other health professionals. This article aims to inform health professionals about the various oral adverse effects that can occur and the most commonly implicated drugs to improve the management, recognition and reporting of adverse drug effects. This article follows on from Part 1; however, the focus here is on lichenoid reactions and oral mucosal disorders including oral aphthous-like ulceration, mucositis and bullous disorders such as drug-induced pemphigus, pemphigoid, Stevens-Johnson syndrome and toxic epidermal necrolysis.

Lichen Planus With Predominate Plasma Cell Infiltrate: Two Case Reports

Lichen planus (LP) is a mucocutaneous inflammatory dermatitis of idiopathic origin that can involve the skin, mucous membranes, hair, and nails. LP has an associated set of characteristic histopathologic findings which include hyperkeratosis, vacuolization of the basal layer, Civatte bodies, wedge-shaped hypergranulosis, band-like lymphocytic infiltrate at the dermal epidermal junction, eosinophilic colloid bodies in the papillary dermis, and pigment incontinence. The infiltrate is usually composed of lymphocytes with few histiocytes, mast cells, and macrophages. The presence of plasma cell predominant infiltrate in LP has only been reported in four previous cases and 2 other cases of lichen nitidus. The authors report another 2 cases of LP with predominate plasma cell infiltrate in 2 female patients on the legs. The differential includes a drug-induced lichenoid reaction with predominate plasma cell infiltrate. However, there have been no case reports of that type of reaction. Because plasma cells are seen commonly in certain infectious diseases, malignancy, and macroglobulinemia, it is prudent to rule out those entities. Our patients responded well with a class 1 topical steroid, with improvement of their lower leg lesions within 1 month of treatment.

Oral and vulvo-vaginal lichenoid reactions due to mitotane (Lysodren): A case report

BACKGROUND

The purpose of pharmacovigilance (drug safety) is collection, detection, assessment, monitoring, and prevention of adverse effects with pharmaceutical products. It is meant to identify, characterize, prevent, or minimize actual or potential risks relating to medicinal products. To prevent these adverse effects and improve our practice, health professionals have a duty to report side effects to assess this risk and evaluate the benefit/risk requirements. Mitotane (Lysodren) is used for treating adrenocortical carcinoma. Currently, no side effects concerning oral and genital mucosa have been reported.

CASE SUMMARY

This case report is about a 50 years old woman. Six months after the initiation on mitotane treatment, she developed erosive lesions located on the oral and vaginal mucosa. These drug reactions were diagnosed as erosive lichen planus by the biopsy. This lichenoid lesions were resistant to the usual treatments, mitotane being at the time not replaceable.

CONCLUSION

This case describes an unreported adverse effect of mitotane, it is - to our knowledge - the 1st description of erosive lichenoid drug reaction due to Mitotane.

Case Report of Lichen Planopilaris Occurring in a Pediatric Patient Receiving a Tumor Necrosis Factor α Inhibitor and a Review of the Literature

A 12-year-old girl with extended oligoarthritis treated with adalimumab presented with a short history of a progressive cutaneous eruption involving the legs and scalp. Physical examination and histologic results were consistent with lichen planopilaris. The adalimumab was discontinued. She received treatment with topical clobetasol propionate and the majority of the lesions resolved. Residual lesions and the extended oligoarthritis were then treated with sulfasalazine. Adalimumab is a tumor necrosis factor α (TNF-α) inhibitor used for the treatment of a variety of immunologically mediated conditions, including lichen planus and lichen planopilaris. TNF-α antagonists have been associated with paradoxical psoriasiform, lichenoid, eczematous, granulomatous, and acneiform eruptions. We detail this case and review the literature of lichenoid reactions secondary to TNF-α inhibitors.

Lichen planus and other lichenoid dermatoses: Kids are not just little people

Lichenoid dermatoses, a group of inflammatory skin conditions with characteristic clinical and histopathologic findings, range from common to rare. Classic lichen planus typically presents as pruritic, polygonal, violaceous flat-topped papules and plaques; many variants in morphology and location also exist. Other lichenoid dermatoses share similar clinical presentations and histopathologic findings. These include lichenoid drug eruption, lichen planus-like keratosis, lichen striatus, lichen nitidus, and keratosis lichenoides chronica. Epidemiologic characteristics vary among each lichenoid disorder. While classic lichen planus is considered a disease of adults, other lichenoid dermatoses may be more common in younger populations. The literature contains an array of reports on the variations in presentation and successful management of lichen planus and lichenoid dermatoses among diverse populations. Familiarity with the characteristics of each lichenoid dermatosis, rare or common within each patient population, is key to accomplishing timely recognition and effective management.

Oral Lichen Planus in IBD Patients: A Paradoxical Adverse Effect of Anti-TNF-α Therapy

INTRODUCTION AND AIMS

The efficacy of tumor necrosis factor alpha (TNF-α) inhibitors in the treatment of Inflammatory Bowel Disease (IBD) is well established. Many cutaneous and mucosal lesions have been described under anti-TNF-α therapy, some of them being considered as paradoxical. In this series we aimed to review the cases of oral lichen planus (OLP) in IBD patients under treatment with anti-TNF-α agents.

METHODS

Histologic findings from oral lesions of IBD patients treated with anti-TNF were revised.

RESULTS

Three female patients with IBD developed oral lichen planus (OLP) after starting anti-TNF-α therapy. Other etiologies were excluded.

CONCLUSIONS

In light of the increasing use of TNF-α inhibitors the occurrence of OLP is a potentially emerging side effect, thus we recommend a careful monitoring for oral manifestations in IBD patients treated with anti-TNF-α agents.

[Delayed-type cutaneous drug reactions. Pathogenesis, clinical features and histology]

BACKGROUND

Cutaneous reactions to drugs can be subdivided in different ways. In addition to the standard classification according to the etiopathogenesis there are also classifications based predominantly on morphological criteria. The majority of drug-related cutaneous adverse reactions are immunological reactions which are collectively classified under the term hypersensitivity. These reactions are based on drug-specific immunoglobulin E (IgE) or cell-mediated mechanisms, not on the mechanism of action of the drug and are unpredictable. Delayed type reactions to drugs are forms of type IV T-cell mediated hypersensitivity. A prerequisite is a stable association of a pharmaceutical substance with a protein so that hapten-protein conjugates can be produced. The most common clinical symptom is maculopapular (morbilliform) drug-related exanthema. This article also examines lichen planus like drug reaction and drug-induced (hematogenic) allergic contact dermatitis in more detail.

DIAGNOSTICS

The diagnostics are never trivial but also include the differentiation from viral exanthema and initial phases of severe cutaneous adverse reactions, such as toxic epidermal necrolysis. In addition to the morphological classification, the final diagnosis encompasses the interpretation of histopathological alterations in the skin biopsy, analysis of patient medication history, laboratory results and inclusion of data from the literature. Patch tests can also have additional diagnostic benefits. In vitro tests which involve the cellular incubation of the drug responsible should be reserved for specialized laboratories. A prerequisite for successful treatment is immediate termination of the drug responsible.

THERAPY AND PROGNOSIS

Therapy is symptomatic with topical and also short-term systemic steroids and antihistamines. The prognosis is very good.

Orofacial adverse effects of biological agents

Biological agents (BA) are increasingly used effectively in the treatment of a range of disorders, but to date, their application in diseases affecting the orofacial region has been fairly limited. Several orofacial adverse effects related to BA have been recently reported. However, the evidence for such adverse reactions is not always strong, and some of the adverse effects of BA have only been reported in case reports or case series. Most reactions to BA reported thus far have been in association with antitumor necrosis factor-α agents, which is not surprising, as these are the most widely-used BA. In the present study, the orofacial adverse effects are reported with various BA in order to sensitize clinicians to the possibilities. In addition, we briefly summarize the mode of action and indications of these BA. As the use and range of BA increases, the number and diversity of adverse effects might well increase. Despite the adverse effects of biological agents, these may often be less serious than the adverse effects of the more traditional immunosuppressive agents.

Immune-mediated inflammatory reactions and tumors as skin side effects of inflammatory bowel disease therapy

All drugs currently used for treating patients with inflammatory bowel disease (IBD - including Crohn's disease and ulcerative colitis) have the potential to induce skin lesions ranging from mild eruptions to more serious and widespread clinical presentations. The number of cutaneous adverse reactions due to IBD therapies is progressively increasing and the most frequently involved drugs are thiopurines and biologics like tumor necrosis factor (TNF)-α antagonists. The main drug-induced cutaneous manifestations are non-melanoma skin cancer (NMSC), notably basal cell and squamous cell carcinomas, and viral skin infections for thiopurines and psoriasiform, eczematoid and lichenoid eruptions as well as skin infections and cutaneous lupus erythematosus for biologics. Cutaneous manifestations should be promptly recognized and correctly diagnosed in order to quickly establish an adequate therapy. The main treatment for NMSC is surgical excision whereas the management of immune-mediated inflammatory skin reactions varies from topical therapy for mild presentations to the shift to another drug alone or in combination with corticosteroids for extensive eruptions.

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.

Infliximab-Induced Lichen Planopilaris

Objective:

To report a case of lichen planopilaris in a patient treated with infliximab for longstanding refractory psoriasis.

Case Summary:

A 37-year-old man with recalcitrant plaque psoriasis was being treated with infliximab at a dosage of 5 mg/kg every 8 weeks, with good response. However, 11 months later the patient developed follicular keratotic papulo-pustules, perifollicular erythema, and scaling, with progressive hair toss of the frontal and parietal regions of the scalp and eyebrows. A skin biopsy from a representative lesion was consistent with the diagnosis of lichen planopilaris.

Discussion:

Anti-tumor necrosis factor (TNF) agents have been associated with numerous cutaneous adverse events. Lichenoid reactions are uncommon but are an emerging cutaneous adverse effect. At least 13 cases of these eruptions have been recently described. Although lichenoid reactions in patients treated with TNF-α inhibitors may be clinically very diverse, we have found no previously reported cases of lichen planopilaris induced by these agents. An objective causality assessment revealed that the adverse event was probable.

Conclusions:

Since anti-TNF agents are being used for a rapidly expanding number of rheumatic, digestive, and dermatologie diseases, it is expected that lichenoid eruptions and other skin toxicities are likely to be seen with increasing frequency in clinical practice.

Lichen planus-like eruptions: an emerging side effect of tumor necrosis factor-alpha antagonists

As tumor necrosis factor (TNF)-alpha inhibitors gain wider use in clinical practice, it is becoming increasingly evident that these potent immunosuppressants can also induce inflammatory reactions. We present two cases of lichen planus-like eruptions after infliximab and adalimumab therapy for psoriasis, and review the literature on this phenomenon. Eleven cases of lichen planus or lichenoid drug eruptions have been previously reported in patients taking TNF-alpha inhibitors, in addition to several cases of psoriasiform eruptions with a lichenoid histology. Because TNF-alpha has been implicated in the pathogenesis of lichen planus, induction of lichenoid reactions by TNF-alpha inhibition is somewhat unexpected. We consider potential immunologic mechanisms, and suggest that TNF-alpha inhibition may precipitate lichenoid reactions through disruption of a delicate balance between TNF-alpha and interferon-alpha in susceptible patients.