Flare and change of psoriasis morphology during the course of treatment with tumour necrosis factor blockers

Abstract

Tumour necrosis factor (TNF) blockers represent an exciting advance in the management of psoriasis. However, the safety profile of these drugs is not completely established. We present a review of the literature, and report on eight patients: two with the unexpected appearance of psoriasis, and the remaining six with exacerbation and change in morphology of their existing psoriasis, all of which occurred during treatment with the TNF blockers adalimumab, etanercept and infliximab. The two new cases, neither of whom had any personal or family history of psoriasis, developed pustular psoriasis on the palms and/or soles. The other six patients, previously diagnosed with severe chronic plaque psoriasis (four patients), generalized pustular psoriasis (one) and erythrodermic psoriasis (one), developed eruptive guttate psoriasis between 15 days and 18 months after the beginning of therapy. These patients had never before presented guttate-type psoriatic lesions, and the lesions appeared in areas of the body that were free of psoriatic plaques at baseline.

Treatment of pustular psoriasis: From the Medical Board of the National Psoriasis Foundation

“…However, the majority of these patients had rheumatoid arthritis or inflammatory bowel disease. 44 Topical therapy may be useful as an adjunct to systemic therapy, or as first-line therapy for localized or mild disease. Case reports document the efficacy of topical calcipotriene (calcipotriol) and topical tacrolimus therapy in GPP.…”

Immunosuppressant supplementation to infliximab in Crohnʼs disease with extraintestinal involvement: A benefit in the long term?

“…4,7 Chronic use of TNF antagonists could lead to disequilibrium between the wide variety of cytokines related to the immune response, resulting in the development of psoriatic lesions or change into the previous cutaneous pattern. 4,6 In conclusion, children could develop adverse cutaneous reactions just as adult patients do. Although the use of anti-TNF-␣ drugs could favor the development of psoriasis in patients with CD, they usually result in dramatic improvement in the intestinal diseases, so the benefits/risks must be evaluated before discontinuing these treatments.…”

Long-Term Control with Etanercept (Enbrel®) of a Severe Acrodermatitis Continua of Hallopeau Refractory to Infliximab (Remicade®)

“…This treatment option should always be considered for this indication, although TNF-inhibitor-induced pustular psoriasis has already been reported, especially in patients, more frequently women, without any history of psoriasis with a predilection for the palms and the soles and to whom the drug was administered for mostly rheumatological conditions [3,4,5,6,7]. The pathogenesis of this adverse event is not yet understood but may be a gap in our understanding of how these molecules work and of the exact aetiology of psoriasis.…”