Rituximab-Induced Psoriasis in a Patient with Granulomatosis with Polyangitis Treated with Adalimumab

Abstract

Rituximab (RTX) is a chimeric B-cell-depleting monoclonal antibody against CD-20 positive cells that has been approved for the induction and maintenance of granulomatosis with polyangiitis (GPA). Reports have identified RTX to cause drug-related psoriasis. Many theories of underlying pathways have been proposed. However, further workup around the mechanism and treatment is required. Here, we present a 38-year-old woman known to have GPA that developed drug-related psoriasis that was successfully treated with treatment discontinuation and starting adalimumab along with a literature review.

Rituximab‐induced psoriasis in a patient with pemphigus vulgaris: A case report and literature review

“…Among the blistering disorders, Bullous pemphigoid is the most common auto‐immune bullous disease associated with psoriasis, 15 followed by pemphigus vulgaris, pemphigus foliaceous, 2,3,15–17 and herpetiform pemphigus 16 . On the other hand, less commonly, there are some reports of pemphigus preceding psoriasis similar to our case 18,19 …”

“…2,3 Since psoriasis has been regarded as a T-cell-driven disease, the T-cell dysregulation after RTX therapy might be responsible for the development of psoriasis. 3 RTX, which is widely used for treatment of pemphigus vulgaris, can be a potential contributing factor for the development of psoriatic plaques in some patients. Several psoriasis cases have been reported following RTX administration in previous studies (Table 1).…”

Treatment approaches to patients with multiple sclerosis and coexisting autoimmune disorders

“…53 In IBD and PsO, the reports for CD20 antibodies have not been as promising: an Icelandic study recently reported a six-fold increased risk of developing an IBD in patients treated with rituximab, 54 and there are several case reports of patients who developed colitis or PsO during an anti-CD20 treatment with rituximab or ocrelizumab. 55–58 Immunity critically relies on the homeostasis of pro and anti-inflammatory stimuli and CD20 + cells have an important regulatory and protective role in the gastrointestinal system 59,60 as well as the skin; 61 thus B cell depletion may trigger an abnormal B cell-mediated T cell regulation and, as a consequence, PsO or IBD. Thus, CD20 antibodies may be the ideal therapeutic for patients with highly active MS and RA, yet should be carefully considered in MS plus IBD/PsO patients.…”

Skin-Associated B Cells in the Pathogenesis of Cutaneous Autoimmune Diseases—Implications for Therapeutic Approaches

“…In several CAD, the specific state and function of Bregs appear to vary: in Psoriasis, deficiency of peripheral blood Bregs leads to significantly decreased expression of IL-10, enabling an upregulated expression of proinflammatory cytokines, amongst them are IFN-y and IL-17 produced by Th1-and Th17-cells, respectively. Accordingly, therapeutic drugs such as Rituximab (RTX), which lead to an unselective depletion of all B cell subsets including protective Bregs, have been found to induce or aggravate psoriatic skin lesions [90][91][92][93][94][95]. In patients with dermatomyositis, remarkably decreased numbers of peripheral blood Bregs compared to healthy controls were observed, which correlated with disease severity [96].…”