Most paradoxical psoriasiform eruptions were managed locally

ORLANDO — Paradoxical psoriasiform eruptions have increasingly been reported among patients with inflammatory bowel disease (IBD) being treated with anti-tumor necrosis factor (TNF) agents, a researcher reported here, describing a case that she had recently seen.

The patient was a 27-year-old woman with IBD who presented with a new-onset itchy rash behind her ears and on her scalp that rapidly progressed and resulted in significant hair loss. Her bowel disease had been well maintained on adalimumab (Humira), said Millie D. Long, MD, of the University of North Carolina at Chapel Hill, speaking at the annual Advances in Inflammatory Bowel Disease meeting.

The rash was psoriasis, a systemic inflammatory disorder with varied manifestations that can be associated with other inflammatory conditions in about 10% of cases.

“What was interesting about this was that the patient was actually on a biologic — adalimumab — that’s approved for the treatment of psoriasis,” Long said. “It appeared that it was the biologic that was driving this process.”

She explained that as the use of biologics has increased over the past 2 decades, more of these paradoxical skin eruptions have been seen. These events were not seen during the initial clinical trials, which suggests that the incidence is low or that the reactions are associated with prolonged treatment, she added.

The largest series of these paradoxical dermatologic events associated with anti–TNF therapy included 917 patients with IBD who initiated treatment with infliximab (Remicade) at University Hospitals Leuven in Belgium from 1994 to 2009. Their medical records were reviewed through 2014.

During the course of follow-up, 29% of patients developed skin lesions. A total of 57% were women, and median age was 36 at the time of initiation of therapy. The median time from treatment initiation to the appearance of lesions was 1.9 years. Three-quarters had Crohn’s disease, and 45% were ever-smokers.

Crohn’s disease most often occurs during maintenance therapy, although cases have been reported as early as 1 month into treatment, Long noted, and typically is seen when the bowel disease is quiescent.

The types of skin lesions most often observed in the Belgian series were psoriasiform eczema in 31% of patients; eczema in 24%; xerosis cutis in 11%; and palmoplantar pustulosis in 5%. All typically developed at flexural regions or on the scalp or genitalia.

The authors of that report noted, “In this cohort, both antinuclear antibody and double-stranded anti-DNA antibody development were more common in patients with skin lesions, suggesting the involvement of possible autoimmune processes in the pathogenesis of skin lesions.”

Long said the vast majority of patients have responded to conservative treatments, which can include topical emollients and steroids, and sometimes changes to systemic therapy. Response rates of up to 90% have been seen with topical treatment or the addition of an immunomodulator, although a small fraction of patients have had to stop the TNF inhibitor.

In that circumstance, a change to ustekinumab (Stelara) can be considered, because the reported response rate has been up to 100% for the treatment of these psoriasiform eruptions, she said.