Skin Side Effects of Inflammatory Bowel Disease Therapy

Abstract

Skin manifestations are common in patients suffering from inflammatory bowel disease (IBD) and can be associated with the disease itself, with nutritional deficiencies, or with therapy. All drugs currently used for treating IBD have the potential to cause dermatologic manifestations that can have a wide range of clinical presentations, from mild drug eruptions to potentially life-threatening immune-mediated reactions. The wider use of thiopurines and anti-tumor necrosis factor in the past years has led to the recognition of 2 more skin complications of IBD therapy: the potentially disfiguring non-melanoma skin cancer associated with the current or past use of thiopurines and the paradoxical new onset or exacerbation of anti-tumor necrosis factor-associated psoriasis. Despite being rare, these complications can be severe and lead to therapy discontinuation, and therefore, gastroenterologists need to become familiar with their epidemiology, diagnosis, and management. Herein, we reviewed the skin side effects of IBD therapy, specially focusing in thiopurines and anti-tumor necrosis factor therapy and in the recently described skin cancer and psoriasis, and we tried to advance some practical algorithms that can provide some help to the clinicians dealing with these complications in their day-by-day practice.

Cumulative Incidence of, Risk Factors for, and Outcome of Dermatological Complications of Anti-TNF Therapy in Inflammatory Bowel Disease: A 14-Year Experience

“…Anti-TNF therapy was pursued in 81% of patients, with switch to another agent in 35.6% and with continuation of the same drug in 46.8% of them. Discontinuation of anti-TNF therapy occurred in 18.6% of patients in our study, which is quite low compared with previous data: indeed, it is estimated that paradoxical psoriasis leads to anti-TNF discontinuation in more than 40% of cases ( 24 ). Continuation of anti-TNF therapy combined to a topical treatment, and eventually a systemic treatment, should be the fi rst option, as cutaneous improvement is possible.…”

“…Switch to another anti-TNF agent was needed in 35.6% of patients with psoriasiform lesions, and was followed by recurrence of psoriasis in 57% of cases. Th ese data confi rm a class eff ect ( 8,21,24 ). In our study, specifi c dermatological management of psoriasis was mainly represented by topical treatments classically used in psoriasis, such as topical corticosteroids and vitamin D analogs.…”

“…At time of onset of psoriasiform lesions, mean duration of anti-TNF therapy was 42.7 months for IFX (range=1-129) and 34.2 months for ADA (range=6.5-88.8). As previously described ( 24 ), the wide range of these results emphasizes the unpredictability of development of psoriasis aft er exposure to anti-TNF, given that it can appear aft er the fi rst administrations or many years aft er the drug was started. Th e type of anti-TNF was not associated with the risk of paradoxical psoriasis.…”

“…Apart from injection site reactions and infusion reactions, anti-TNF-induced psoriasiform lesions are the most frequent dermatological complications observed, occurring in 1.6-8.8% of IBD patients ( 13,(18)(19)(20)(21)(22). Management of such adverse reactions can be challenging in clinical practice for gastroenterologists and dermatologists, leading to anti-TNF discontinuation in up to 40% of IBD patients ( 24 ). Data on the incidence, the management, and the outcome of cutaneous side eff ects in a large cohort of IBD patients treated with anti-TNF are lacking.…”

ACG Clinical Guideline: Preventive Care in Inflammatory Bowel Disease

“…Although not evidence based, this logical approach has been suggested by some individuals ( 124 ). In addition, based on the results from the CESAME study, skin surveillance strategies need to be maintained even aft er stopping thiopurine therapy; which diff ers from the recent date of the nationwide VA cohort study.…”