Psoriasis Associated With Tumor Necrosis Factor Inhibitors in Children With Inflammatory Diseases

Abstract

Objective To estimate the incidence rate (IR) of psoriasis in children with inflammatory bowel disease (IBD), juvenile idiopathic arthritis (JIA), and chronic noninfectious osteomyelitis (CNO) with tumor necrosis factor inhibitor (TNFi) exposure as compared to children without TNFi exposure and to the general pediatric population. Methods This was a single‐center retrospective cohort study of children with IBD, JIA, or CNO from 2008 to 2018. TNFi exposure was defined as a prescription for adalimumab, etanercept, infliximab, certolizumab, or golimumab, and the primary outcome was incident psoriasis. IRs and standardized incidence ratios (SIRs) were calculated. Cox proportional hazards models were used to assess the association of psoriasis with TNFi exposure and other risk factors. Results Of the 4,111 children who met inclusion criteria, 1,614 (39%) had TNFi exposure and 2,497 (61%) did not, with 4,705 and 6,604 person‐years of follow‐up, respectively. There were 58 cases (IR 12.3 per 1,000 person‐years) and 25 cases (IR 3.8 per 1,000 person‐years) of psoriasis in children with and without TNFi exposure, respectively. The SIR was 18 (95% confidence interval [95% CI] 15–22) overall, 30 (95% CI 23–39) for children with TNFi exposure, and 9.3 (95% CI 6.3–14) for children without TNFi exposure. The hazard ratio of psoriasis comparing TNFi exposure to no TNFi exposure was 3.84 (95% CI 2.28–6.47; P < 0.001). Conclusion Children with IBD, JIA, and CNO had an increased rate of psoriasis compared to the general pediatric population, with the highest rate in those with TNFi exposure.

Prevalence of Paradoxical Psoriasis after Exposure to Tumor Necrosis Factor Inhibitors (TNFi) in Children - Results from A Single Tertiary Center

“…TNFi-associated psoriasis is more common in patient populations with IBD and CNO compared to patient populations with JIA. The cumulative incidence rates of paradoxical psoriasis in IBD, CNO, and JIA from this cohort (5.6%, 14.0%, 0.5%) were not directly comparable to the report from Buckley et al [2]. The incidence rate of TNFi-associated psoriasis within children with IBD was 10.9 per 1,000 patient years, 33.5 per 1,000 patient years within children with CNO and 14.7 per 1,000 patient years within children with JIA.…”

“…In a study by Tollefson et al, incidence rates of pediatric psoriasis were calculated (age and sex adjusted to 2000 American Caucasian population) with an overall age-and sex-adjusted annual incidence was 40.8 per 100,000 (95% CI: 36.6-45.1) and was 33.2 per 100,000 (95% CI: 29.3-37.0) when diagnosed by a dermatologist [12]. The standardized incidence ratio for all 3 primary diseases combined was 9.3 without exposure and 30 with exposure to TNFi compared to the general pediatric population [2].…”

“…Tumor necrosis factor inhibitors (TNFi) have demonstrated robust e cacy in the management of numerous in ammatory conditions including chronic nonbacterial osteomyelitis (CNO), juvenile idiopathic arthritis (JIA), in ammatory bowel disease (IBD) and psoriasis. Exposure to TNFi has been associated with the development of psoriasiform eruptions [1][2][3][4][5][6][7][8][9][10]. This paradoxical psoriasis after exposure to TNFi has been increasingly reported in the adult population, however systematic studies in pediatric population are lacking.…”

“…This paradoxical psoriasis after exposure to TNFi has been increasingly reported in the adult population, however systematic studies in pediatric population are lacking. Recently a single center followed the systematic development of paradoxical psoriasis in pediatric patients taking TNFi [2], however most case series available solely describe the courses of disease. The various risk factors, possible preventative measures, demographic trends, pathogenesis, clinical predictive risk information, and optimal treatment plans are still not well characterized or understood.…”

Psoriasis rate is increased by the exposure to TNF inhibition in children with JIA

“…Tumour necrosis factor inhibitors (TNFi) have been approved to treat juvenile idiopathic arthritis (JIA) in children. Children with underlying conditions including JIA, inflammatory bowel disease (IBD) and chronic non-bacterial osteomyelitis (CNO) treated with TNFi may develop psoriasis after exposure to TNFi which is sometimes called paradoxical psoriasis, as TNFi also effectively treat psoriasis 1–6. The most common paediatric presentations included plaque and palmoplantar pustular psoriasis with similar anatomical distribution to psoriatic lesions not associated with TNFi use 7.…”