Paradoxical and bimodal immune-mediated dermatological side effects of TNF-α inhibitors: A comprehensive review

INTRODUCTION

Due to the increasing prevalence of immune-mediated diseases such as psoriasis, lichen planus, rheumatoid arthritis and inflammatory bowel disease, dermatologists have turned to new biologic drugs known as DMARDs (disease-modifying anti-rheumatic drugs) in recent years.

AREAS COVERED

In this study, we evaluate the immune-mediated dermatological side effects of DMARDS by reviewing and analyzing previous peer-reviewed research on the effects of TNF-α inhibitors in the treatment of skin diseases, as well as adverse effects of these drugs and some of the main causes of these effects.

EXPERT OPINION

DMARDs are very effective in improving control of the above diseases. TNF-α inhibitors are an important group of DMARDs that are widely used. The paradoxical adverse events (PAEs) associated with the use of TNF-α inhibitors are divided into three categories: true paradoxical, borderline paradoxical, and non-paradoxical. True PAEs include conditions for which TNF-α inhibitors are approved for treatment. Borderline PAEs are considered to occur with this class of drugs for which there is no definite approval but for which there is sufficient evidence. Although these events are rare, early recognition of the accused drug and appropriate decision-making may prevent progression of complications and irreversible side effects.

Revolutionizing Dupilumab Treatment in Refractory Eosinophilic Cellulitis: A Case Report and Comprehensive Literature Review

Eosinophilic cellulitis (EC) or Wells' syndrome, characterized by its rarity and diverse clinical presentations, presents substantial challenges in diagnosis and treatment. This case study details the challenging journey of a 48-year-old woman with non-specific skin lesions, showcasing the persistence of dermatitis despite exhaustive attempts at various interventions outlined in the literature. In the absence of a consensus on optimal management for EC, this study introduces a transformative solution through the utilization of dupilumab, a monoclonal antibody targeting interleukin-4/interleukin-13. The patient experienced marked improvement and resolution of dermatitis following dupilumab treatment alone, highlighting the efficacy of this targeted immunomodulatory approach in cases refractory to traditional therapies. This pioneering case underscores the significance of exploring innovative treatments and suggests dupilumab as a potential breakthrough therapeutic option in addressing EC refractory to standard medical management.

[A CASE OF ALLERGIC RHINITIS WHO HAS DEVELOPED EOSINOPHILIC PNEUMONIA, FOLLOWED BY EOSINOPHILIC CELLULITIS]

A-68-year-old man, who has allergic rhinitis with peripheral blood eosinophilia, hospitalized because of fever of unknown origin in May 2020. Five days after antibiotics were given, itchy exanthema occurred, followed by gland glass opacity on both lungs with bilateral pleural effusions. Since acute respiratory failure developed, bronchoscopy was hard to carry out. However, this case was considered acute eosinophilic pneumonia induced by antibiotics, based on radiological findings and laboratory data. Therefore, steroid pulse therapy using intravenous administration of methylprednisolone started, and this therapy was effective. Since these chest shadows and hypoxia were disappeared in two weeks, the amount of steroid was gradually reduced, however, eosinophilic pneumonia recurred once during this course. After discharge in June 2020, this patient came to the outpatient department. When oral administration of prednisolone was decreased less than 2.5mg/day, redness and swelling with slight itch were appeared in the left forearm in September 2020. Histological findings from shin biopsy showed that eosinophils excessively invade to the dermis without angiitis. Although flame figure was not observed in the specimen, we considered that this case has developed eosinophilic cellulitis, based on the clinical manifestation and pathological findings. When prednisolone was increased to 30mg/day, these symptoms were improved, and then prednisolone was gradually reduced. After that, recurrences of these diseases did not occur during the observation period. This case may be diagnosed as hypereosinophilic syndrome since eosinophilic pneumonia and eosinophilic cellulitis caused continuously by recruitment of eosinophils to lung and skin.

Luna stain: a simple and cost-effective diagnostic tool helps in detecting eosinophilic granules deposition of flame figures and aids in diagnosing eosinophilic cellulitis "Wells Syndrome"

We report a rare case of Wells syndrome in which a 61-year-old Caucasian male presented with three distinct skin lesions including a cutaneous bulla, an erythematous plaque, and a linear streak located on the patient's left anterior thigh, left dorsal wrist, and left anterior forearm, respectively. Histologic examination revealed diffuse and interstitial eosinophilic infiltrate admixed with lymphocytes and macrophages that predominantly involve the dermis. Nodular aggregates of eosinophils surrounding dermal collagen fibers suggestive of 'flame figures' were identified. Luna histochemical stain was used and highlighted the deposition of eosinophilic granules over the collagen bundles confirming the presence of flame figures. Laboratory workup revealed peripheral eosinophilia, but a comprehensive clinical evaluation failed to reveal a systemic disease and ultimately the diagnosis of eosinophilic cellulitis 'Wells Syndrome' was rendered. After a short course of immunosuppressive therapy, the patient experienced a complete resolution of the skin lesions on his last follow-up visit several weeks from the initial diagnosis. This case highlights the various clinical forms that Wells syndrome may present with and may serve as a good example for the use of Luna stain as a simple and cost-effective diagnostic tool that can help to arrive at the accurate diagnosis and inform therapy.

Insect bites as a trigger factor of eosinophilic cellulitis

INTRODUCTION

The study presents the case report of a Wells Syndrome in a 18-year -ld female. Wells Syndrome is a rare inflammatory skin disorder which seems to present an abnormal eosinophilic response to a number of triggers.

OBJECTIVE

The aim of the study is to discuss several problems related to the diagnosis and treatment of Wells Syndrome.

MATERIAL AND METHODS

Medical examination, blood tests, abdominal ultrasound and skin biopsy were performed.

RESULTS

Medical examination revealed plaques with tense blisters on feet and erythematous lesions on trunk. Blood tests showed raised anti-streptolysin O level. Skin biopsy revealed features of eosinophilic cellulitis. Oral administration of 0.5 mg per day prednisolone and antihistaminics with local therapy resulted in good clinical response.

CONCLUSIONS

Sometimes several biopsy are required to establish diagnosis. In some cases lower doses of corticosteroids with antihistaminics and local anti-inflammatory treatment can by sufficient in treatment.

A review of cutaneous hypersensitivity reactions in infants: From common to concerning

Cutaneous hypersensitivity reactions in infants present in a variety of patterns. These skin eruptions can be dramatic, causing alarm in parents and medical personnel. Many of these syndromes have overlapping features, which adds to the confusion and uncertainty regarding diagnosis and management. This review discusses the spectrum of hypersensitivity responses with a focus on their presentation in infants. The clinical findings, pathophysiology, histopathology, management, and complications of these conditions will be reviewed.

Pediatric Wells syndrome (eosinophilic cellulitis) after vaccination: A case report and review of the literature

A 4-year-old boy presented with erythematous vesicular plaques, ulceration, edema, and pruritus on the left foot and ankle 10 days after receiving the tetanus, diphtheria, pertussis, and polio; measles, mumps, rubella, and varicella; and hepatitis A/B vaccines. Biopsy showed eosinophilic infiltrates and flame figures, suggesting Wells syndrome. Patch testing showed a 1+ reaction to neomycin and aluminum hydroxide, with a recall reaction of Wells syndrome of the feet bilaterally. We report a rare case of pediatric Wells syndrome triggered by nonthimerosal vaccine components confirmed by patch testing.

Eosinophilic cellulitis (Wells' syndrome) caused by a temporary henna tattoo

Eosinophilic cellulitis (Wells' syndrome) is an uncommon condition of unknown etiology. Wells' syndrome is usually seen in adulthood but very rare in childhood. Although pathogenesis of the disease is not very clear, it is a hypersensitivity reaction developing against a variety of exogenous and endogenous antigenic stimuli. Paraphenylenediamine is a strong allergen frequently used as a temporary henna tattoo, which makes the color darker. Here, a 9-year-old male patient with Wells' syndrome is presented, which developed following a temporary henna tattoo and shown by the patch test sensitivity to paraphenylenediamine.