Elsevier

Joint Bone Spine

Volume 75, Issue 3, May 2008, Pages 315-318
Joint Bone Spine

Original article
Onset or exacerbation of cutaneous psoriasis during TNFα antagonist therapy

https://doi.org/10.1016/j.jbspin.2007.06.011Get rights and content

Abstract

The widespread use of TNFα antagonists in recent years has led to the recognition of paradoxical adverse effects, defined as the onset or exacerbation of disorders that are usually improved by TNFα antagonists. Cutaneous psoriasis is an example, of which several cases have been reported.

Objective

To identify cases of psoriasis onset or exacerbation during TNFα antagonist therapy and to look for potential predictive factors.

Methods

We retrospectively reviewed cases of psoriasis onset or exacerbation during TNFα antagonist therapy. For each case we recorded the following data: age, sex, underlying disease, nature of the TNFα antagonist, effectiveness in improving the underlying disease, history of psoriasis in the patient or family, time to psoriasis development, type of psoriasis (confirmed by an experienced dermatologist), concomitant treatments, whether the TNFα antagonist was stopped or continued, and the outcome of the psoriasis. These data were compared to those in the literature.

Results

We identified 12 patients, six men and six women, with a mean age of 45.5 years. The TNFα antagonist was adalimumab in four patients, etanercept in six patients, and infliximab in two patients. The underlying disease was ankylosing spondylitis in six cases, rheumatoid arthritis in four, and psoriatic arthritis in two. Mean time from treatment initiation to psoriasis was 4.1 months (range, 1–15 months). A previous history of psoriasis in the patient was noted in six cases, including four of the six patients taking etanercept. TNFα antagonist therapy was effective on the underlying disease in 11 of the 12 patients. The drug was discontinued in five patients, of whom four experienced resolution of their psoriasis. In the remaining seven patients, the drug was continued and the skin lesions remained unchanged. Most of the patients had psoriasis vulgaris (plaque psoriasis); palmoplantar pustulosis was a feature in five patients.

Discussion

Over 40 cases of psoriasis onset or exacerbation during TNFα antagonist therapy have been reported in the literature. The prevalence of this adverse effect has been estimated at 1.5–5% of patients taking TNFα antagonists. The findings from our case series are consistent with data in the literature. Psoriasis is a class effect that has been reported with all the currently available TNFα antagonists. The skin lesions develop within the first few months of therapy. Patients with a wide range of underlying diseases can be affected. Palmoplantar pustulosis is a common feature. A previous history of psoriasis seems more common in patients who experience psoriasis onset or exacerbation during etanercept therapy (four of six patients in our study and 55% in the literature); thus, previous psoriasis may be a risk factor for psoriasis exacerbation during etanercept therapy.

Introduction

TNFα antagonists have been found effective in various rheumatic and nonrheumatic diseases. The increasing use of these agents has led to the recognition of several paradoxical adverse effects. One example is the new onset or exacerbation of cutaneous psoriasis. TNFα antagonists are effective in treating psoriasis and are licensed for use in patients with severe forms of the disease. We retrospectively identified 12 cases of psoriasis onset or exacerbation during TNFα antagonist therapy.

Section snippets

Methods

We conducted a retrospective observational study of patients with new onset or exacerbation of cutaneous psoriasis during treatment with TNFα antagonists for a variety of diseases. All the patients were evaluated at our hospital departments.

For each patient, we recorded the following data: age, sex, underlying disease with its duration, time from TNFα antagonist initiation to psoriasis onset or exacerbation, type and dosage of the TNFα antagonist, concomitant treatments, previous history of

Results

We identified 12 patients, whose main characteristics are shown in Table 1. There were six women and six men, with a mean age of 45.5 years. Of the 12 patients, six were taking etanercept, four adalimumab, and two infliximab. The drugs were used in standard dosages. The underlying disease was ankylosing spondylitis or another spondyloarthropathy in six patients, rheumatoid arthritis in four patients, and psoriatic arthritis in two patients. A previous history of psoriasis was noted in six

Discussion

We report on 12 cases of psoriasis onset or exacerbation during TNFα antagonist therapy for a variety of diseases. Three different TNFα antagonists were involved.

This side effect may seem paradoxical, given that TNFα antagonists are used to treat severe forms of psoriasis. About 40 similar cases have been reported in the medical literature [1], [2], [3], [4], [5], [6], [7], [8], [9], [10]. Psoriasis occurred during six of 400 TNFα antagonist treatments at a rheumatology center [2] and in five

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