Cutaneous Manifestations of Reactions to Biologics

Abstract

Anti-TNF agents and immune checkpoint inhibitors have significant, immune-mediated cutaneous manifestations that can necessitate discontinuation. Anti-TNF agents, IL-6 inhibitors, and IL-12/23 inhibitors can paradoxically cause psoriasis flares or unmask previously undiagnosed psoriasis. IL-17 inhibitors are unique in increasing risk for Candida infections. Benign injection site reactions, non-specific rash, cellulitis, and hypersensitivity reactions are relatively common adverse events. A wide variety of cutaneous reactions caused by biologics have been reported, ranging from benign injection site reactions to life-threatening cutaneous reactions necessitating discontinuation of the implicated biologic agent.

Morphea in a patient undergoing treatment with ustekinumab

“…Common adverse effects of ustekinumab include headaches, fatigue, abdominal pain, and upper respiratory infections 2 . Few cutaneous side effects have been reported 3 . Although there was concern that the drug might increase the risk of nonmelanoma skin cancer because of blockade of IL-12 antitumor activity, clinical data have not shown this to be the case 2, 3.…”

“…Few cutaneous side effects have been reported 3 . Although there was concern that the drug might increase the risk of nonmelanoma skin cancer because of blockade of IL-12 antitumor activity, clinical data have not shown this to be the case 2, 3. Multiple immunologically based dermatologic conditions, namely alopecia areata, linear IgA bullous dermatosis, and eczematous and lymphomatoid drug reaction, have been reported in conjunction with this drug 3 …”

Adverse Reactions to Biologic Medications Used in Allergy and Immunology Diseases

“…Delayed reactions have also been reported with biologics, including more common reactions such as mild delayed maculopapular eruptions and serum sickness-like reactions (SSLRs). Of the biologic agents discussed in this review, SSLRs have been most frequently reported with rituximab and infliximab, but have also been reported to dupilumab and omalizumab [19][20][21][22][23][24]. Severe cutaneous adverse reactions such as Stevens-Johnson Syndrome/toxic epidermal necrolysis have been reported but are significantly more rare [25,26].…”

Dermatologic adverse events caused by biologic treatments – Pathogenesis and management

“…Reported symptoms include pruritus, flushing, hives and rash, and delayed urticaria/angioedema, most likely caused by IgE antibodies directed against non-self peptide sequences in the chimeric structure. 21 Local injection site reactions (Figure 5a) including pain, swelling, erythema, are described for most biologics. 22 In addition to irritation, type IV allergic reactions are also described, but it is not always possible to distinguish between the different reaction types.…”