Can biologic treatment induce cutaneous focal mucinosis?

Abstract

Skin mucinosis is a rare skin disease which clinically manifests as firm papules and waxy nodules. We report a case of a 66-year-old female psoriatic patient who developed skin mucinosis during biological therapy. Because of a previous lack of response to the local and conventional systemic treatment of psoriasis, the patient received biological therapy (infliximab from June 2008 to May 2009 – initial clinical improvement and loss of treatment effectiveness in the 36th week of the therapy; adalimumab from June 2009 to January 2010 – lack effectiveness; ustekinumab from March 2012 to the present). Throughout 2 months we observed a manifestation of the skin mucinosis as well-demarcated, yellow and brown, papulo-nodular lesions of 5–10 mm in diameter, localized on the back. Histopathological examination with alcian blue staining demonstrated mucin deposits in the dermis. On the basis of clinical and histopathological findings, the diagnosis of cutaneous focal mucinosis was established. We present the case because of the extremely rare occurrence of the disease. Scarce literature and data suggest that there is an association between focal mucinosis and thyroid dysfunction, as well as possible adverse effects of biological therapy with TNF-α antagonists.

Cutaneous mucinosis in a patient taking ustekinumab for palmoplantar psoriasis

“…The patient's treatment course was remarkably similar to our patient's: she presented with the lesions after 8 weeks of treatment with ustekinumab and MTX and had previously failed multiple TNF inhibitors [6]. Given the brevity of her course of ustekinumab and MTX, the authors attributed the mucin deposition to the 1.5 years of exposure to TNF inhibitors [6]. An additional case in the French literature also suggests a possible role of TNF inhibitors in multiple lesions of focal cutaneous mucinosis [8].…”

“…Localized LM in association with systemic psoriasis therapy is especially rare (Table 2). To date, one study in the English literature reports the development of multiple focal cutaneous mucinosis, a term which generally corresponds to localized LM [1], after systemic immunotherapy for plaque psoriasis [6]. The patient's treatment course was remarkably similar to our patient's: she presented with the lesions after 8 weeks of treatment with ustekinumab and MTX and had previously failed multiple TNF inhibitors [6].…”

“…Dermal mucin is produced in small amounts by fibroblasts in normal situations and consists predominantly of the glycosaminoglycan hyaluronic acid (HA) [5]. Although the reason for mucin overproduction in DPLM is uncertain, immunoglobulins and cytokines, such as interleukin-1 (IL-1), tumor necrosis factors (TNF), transforming growth factor-β (TGF-β), or interferon-γ (IFN-γ) have been implicated in the stimulation of HA synthesis by dermal fibroblasts or dermal dendrocytes [6,7]. Psoriasis is characterized by an upregulation of similar proinflammatory cytokines that could theoretically stimulate dermal fibroblasts to produce excess HA, leading to DPLM, though this has not yet been validated in the literature [6].…”

“…To date, one study in the English literature reports the development of multiple focal cutaneous mucinosis, a term which generally corresponds to localized LM [1], after systemic immunotherapy for plaque psoriasis [6]. The patient's treatment course was remarkably similar to our patient's: she presented with the lesions after 8 weeks of treatment with ustekinumab and MTX and had previously failed multiple TNF inhibitors [6]. Given the brevity of her course of ustekinumab and MTX, the authors attributed the mucin deposition to the 1.5 years of exposure to TNF inhibitors [6].…”

Trauma-induced focal nodular mucinoses: A rare entity

“…However, multiple focal cutaneous mucinoses have been seen as a side effect of anti-TNF-α therapy in a psoriatic patient. [ 5 ] Furthermore, trauma as an inciting factor has been seen in two cases till date which later progressed to CFM. [ 4 ]…”