TNF-α inhibitor induced pigmented purpuric dermatoses: a case report

Abstract

Background We present a rare case of TNF-α inhibitor induced pigmented purpuric dermatoses (PPD) and explore its mechanisms and management. Case presentation A 44-year-old woman presented with non-pruritic non-tender petechial rash on bilateral lower limbs after being started on Adalimumab, with the rash progressing to worsen on Golimumab, both used for managing her seronegative peripheral arthritis. Laboratory panel revealed a negative vasculitis screen and skin biopsy confirmed the condition. After ceasing the TNF-α inhibitors and changing to Secukinumab, an Interleukin-17 inhibitor, the lesions stopped erupting and slowly resolved. Conclusion PPD is a benign skin condition and has been associated with various medications and exposure to chemicals in the literature. Different mechanisms have been proposed in the literature however its exact aetiology is unknown. To date, there is no standardized treatment however patients should be reassured that PPD is benign and will often regress by itself once the causative agent has been removed.

A case of certolizumab‐induced purpura annularis telangiectodes of Majocchi and literature review

“…4 Similarly, in the case of Jhaveri et al, PPD occurred 2 weeks after adalimumab administration, and the lesions increased after switching to golimumab 3 months later. 7 In contrast, in the case of Lebas et al, the lesions did not worsen despite continued infliximab. 5 All PPDs result from minimal inflammation and hemorrhage of superficial papillary dermal vessels, usually capillaries.…”

“…However, there are case reports of PPD induced by infliximab, adalimumab and golimumab and in our case, certolizumab pegol was the culprit (Table 1). [4][5][6][7] In the case of Wang et al, PPD developed in the 5th infusion (5 mg/kg: weeks 0, 9, 18, 26, 34) of infliximab and worsened with the 6th infusion. 4 Similarly, in the case of Jhaveri et al, PPD occurred 2 weeks after adalimumab administration, and the lesions increased after switching to golimumab 3 months later.…”

“…It is perhaps therefore why vasculitis is often mentioned among the cutaneous side effects of TNFα inhibitors, whereas PPD has been reported in only a few case reports. [4][5][6][7] PPD must be differentiated from vasculitis for proper patient management. Histopathological examination has a great place in the differentiation of these 2 diseases.…”

“…PPD cases may be misdiagnosed as vasculitis due to the similarity of their clinical presentations. It is perhaps therefore why vasculitis is often mentioned among the cutaneous side effects of TNFα inhibitors, whereas PPD has been reported in only a few case reports 4–7 . PPD must be differentiated from vasculitis for proper patient management.…”

“…9 The existence of studies suggesting that the cell-mediated immune response plays a role in the pathogenesis of PPD supports that the immunogenicity of TNFα inhibitors may induce PPD. 3,7 The skin is often affected in paradoxical reactions due to biological agents. Psoriasis, hidradenitis suppurativa, granulomatous skin diseases, neutrophilic dermatoses, vasculitis, and lupus erythematosus are more frequently reported among paradoxical inflammatory skin diseases due to TNFα inhibitors.…”