Sequential paradoxical psoriasiform reaction and sacroiliitis following adalimumab treatment of hidradenitis suppurativa, successfully treated with guselkumab

Abstract

Paradoxical reactions during treatment with a biologic agent are defined by the appearance or exacerbation of a pathological condition that usually responds to this drug while treating another condition. A 26-year-old woman presented with a 3-year history of Hurley Stage III hidradenitis suppurativa (HS) involving the groin, buttocks, and pubis, which had been refractory to topical antibiotics and corticosteroids, doxycycline, rifampicin, and clindamycin in combination. F I G U R E 1 Hurley stage III Hidradenitis suppurativa and paradoxical psoriasiform reaction to adalimumab. A,B, Inflammatory nodules and abscesses in the groin and pubis (Hurley Stage III, Physician's Global Assessment 4) together with erythemato-desquamative plaques on the legs and C, palms with pustules and D, extensive alopecia patches on the scalp secondary to desquamative plaques. Because of the severity of hair loss, the patient herself shaved the remaining hair and had to wear a wig.

Paradoxical psoriatic arthritis in a patient with psoriasis treated with guselkumab

“…There is only one case of PsA flare (in a patient with long‐standing PsA) that appeared to be triggered by guselkumab 5 . Conversely, a case of concomitant hidradenitis suppurativa, sacroiliitis and paradoxical psoriasiform reaction to adalimumab was successfully treated with guselkumab 7 and a case of a palmoplantar pustular reaction (in a patient with severe psoriasis treated with ixekizumab) was successfully treated with guselkumab 6 …”

Guselkumab in the treatment of severe hidradenitis suppurativa, a promising role?

“…We administered the psoriasis dosage regimen as in many previous cases: in fact, so far only four patients were treated with a higher dosage (100 mg every 4 weeks), however, without a greater advantage. 7 We observed a significant improvement in our patient at week 16, according to literature review, [3][4][5][6][7] but a long follow-up period is needed to confirm the high response rate.…”

“…In a few previous studies, guselkumab showed good results in Hurley stage II or III HS patients, not all presenting a concomitant or induced psoriatic condition. [3][4][5] It is reported that IL-23/Th-17 pathways, over expressed in immunopathological features of psoriasis and paradoxical psoriasiform reactions, could play a crucial role in the pathogenesis of HS including IL-23, highly expressed by macrophages infiltrating affected skin. 6 Since our patient developed vulgar psoriasis during therapy with adalimumab without clinical improvement, guselkumab was elected as second-line biological therapy.…”

Paradoxical Hidradenitis Suppurativa during Biologic Therapy, an Emerging Challenge: A Systematic Review

“…Adalimumab, a fully human monoclonal IgG1 antibody directed toward membrane-bound TNF α is the only FDA-approved biologic therapy for moderate to severe HS [ 6 , 23 , 24 ]. The approved standard dosing regimen of adalimumab is 160 mg at baseline (week 0), and 80 mg at week 2, followed by 40 mg weekly from week 4 [ 16 , 25 , 26 , 27 , 28 ]. Some cases of paradoxical HS have been reported in patients suffering from chronic inflammatory bowel diseases treated with adalimumab who developed moderate to severe forms of paradoxical HS [ 20 , 29 ].…”