Autoimmune Bullous Skin Diseases Occurring under Anti-Tumor Necrosis Factor Therapy: Two Case Reports

Abstract

Background: Anti-tumor necrosis factor (TNF) agents are increasingly being used for a rapidly expanding number of rheumatic and systemic diseases. As a result of this use, and of the longer follow-up periods of treatment, there are a growing number of reports of the development of autoimmune processes related to anti-TNF agents. The use of anti-TNF agents has been associated with more and more cases of autoimmune diseases, principally cutaneous vasculitis, lupus-like syndrome, systemic lupus erythematosus and interstitial lung disease. Observations: We report 2 cases of autoimmune bullous skin disease occurring in patients undergoing TNF-targeted therapy: a bullous pemphigoid and a pemphigus foliaceus. Both patients were treated by anti-TNF agents for rheumatoid arthritis and showed improvement following interruption of that treatment. Here, we discuss the relationship between anti-TNF therapy and the occurrence of autoimmune bullous disease. Conclusion: Anti-TNF agents should be considered as a potential cause of drug-induced autoimmune bullous skin disease.

Linear IgA Bullous Dermatosis Secondary to Infliximab Therapy in a Patient with Ulcerative Colitis

“…This does not prove an inherent therapeutic effect of anti-TNF-α in LABD as the regeneration of the intestinal epithelial barrier induced by IFX may have been responsible for the beneficial effect on the LABD in that case. Other case reports link the development and exacerbation of the autoimmune bullous dermatoses pemphigus foliaceus, bullous pemphigoid [12] and dermatitis herpetiformis [23] to previous TNF-α antagonist treatment. The ‘paradoxical' development of autoimmune diseases under TNF-targeted therapies has been described before with psoriasis vulgaris, which can be successfully treated, but also triggered by anti-TNF-α treatment in some patients with IBD or arthritis [24,25].…”

“…Thus far, there is no published case report considering infliximab (IFX) or another tumor necrosis factor-α (TNF-α) inhibitor as the inducing agent of LABD. However, there is one case report each of a bullous pemphigoid and a pemphigus foliaceus developing under anti-TNF-α therapy [12]. LABD can usually be successfully treated using dapsone with or without oral steroids [6].…”

Amicrobial Pustulosis-Like Rash in a Patient with Crohn’s Disease under Anti-TNF-Alpha Blocker

“…Since the introduction of anti-TNF treatment, an increasing number of cutaneous adverse reactions have been recognized including psoriasiform and pustular eruptions, lupus-like disorders, dermatomyositis, vasculitis, granulomatous reactions, infections, infusion and injection site reactions and malignancies [21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38]. These entities have been summarized in table 2.…”

Association of Linear IgA Bullous Disease with Ulcerative Colitis: A Case of Successful Treatment with Infliximab

“…Conversely, anti-TNF-α agents have been reported to induce autoimmune bullous diseases [11]. This might be considered another example of a paradoxical reaction, as has been described in the case of psoriasis [12].…”