|Year : 2018 | Volume
| Issue : 1 | Page : 36-38
Anti-tumor necrosis factor-induced palmoplantar psoriasis: Case series
Department of Dermatology, College of Medicine, Al-Imam Muhammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
|Date of Web Publication||31-Jan-2018|
Dr. Saad Altalhab
Department of Dermatology, College of Medicine, Al-Imam Muhammad Ibn Saud Islamic University, P. O. Box: 5701, Riyadh 11432
Source of Support: None, Conflict of Interest: None
Palmoplantar pustular psoriasis (PPP) is a very uncommon form of psoriasis. Patients usually present with sterile, intraepidermal pustules over palms and soles, and it is difficult to treat. Women and smokers may be at a higher risk of getting PPP. Here, we report 2 patients who developed new PPP lesions after initiation of adalimumab (Humira®). Case reports are for a 19-year-old female diagnosed with Crohn's disease on February 2012 after a long history of abdominal pain and bleeding and a 34-year-old female who had psoriatic arthritis with no skin lesions since November 2012. Our recommendation is for the patients to be controlled with potent topical corticosteroids, keratolytics, Vitamin D analogs, phototherapy, increases in baseline methotrexate doses, and cyclosporine as needed.
Keywords: Adalimumab, Crohn's disease, palmoplantar psoriasis
|How to cite this article:|
Altalhab S. Anti-tumor necrosis factor-induced palmoplantar psoriasis: Case series. J Dermatol Dermatol Surg 2018;22:36-8
| Introduction|| |
Palmoplantar pustular psoriasis (PPP) is a very uncommon form of psoriasis. Patients usually present with sterile, intraepidermal pustules over palms and soles, and it is difficult to treat. Women and smokers may be at a higher risk of getting PPP. Although many treatment options are available, there is no standard therapy for the management of PPP. In addition, PPP may cause significant physical disability, and the current methods of treatment are generally inadequate.
Tumor necrosis factor-alpha (TNF-α) is a proinflammatory cytokine that is linked to many inflammatory disorders including psoriasis, rheumatoid arthritis (RA), spondyloarthropathies, and inflammatory bowel diseases. The treatment options for these diseases usually include TNF-α antagonists. In psoriasis, including psoriatic arthritis, TNF-α antagonists are indicated with favorable results. Three TNF-α antagonists are currently approved for the treatment of psoriasis: etanercept (Enbrel ®), infliximab (Remicade ®), and adalimumab (Humira ®). Adalimumab is a fully human immunoglobulin G1 antibody that works by blocking TNF activity through binding to soluble and membrane-bound TNF.
Despite effectiveness of anti-TNF agents in treating psoriasis, there are more than 200 cases in literature reporting occurrence of psoriasiform lesions or exacerbation of existing psoriatic lesions following anti-TNF therapy. Here, we report two patients who developed new PPP lesions after initiation of adalimumab (Humira ®).
| Case Reports|| |
A 19-year-old female had diagnosed with Crohn's disease on February 2012 after a long history of abdominal pain and bleeding. On March 2012, a gastroenterologist had prescribed her adalimumab 40 mg weekly. The patient was doing well regarding Crohn's disease until October 2015 when she developed pustular eruption on palms and soles [Figure 1]. She sought medical advice at our dermatology department and skin biopsy was taken and showed psoriasiform pattern with dilated capillaries. Following the biopsy results, a combined team of dermatologists and gastroenterologists decided to prescribe her methotrexate 15 mg weekly with 1 mg daily folic acid and continue on adalimumab with the same dose. In addition, betamethasone dipropionate 0.05% ointment was added to maximize the improvement. After 2 months, the patient showed approximately 90% improvement. The last follow-up visit was on June 2016 and the patient was still in remission.
|Figure 1: Clinical images (a and b) showing multiple hyperkeratotic plaques over both feet with few dried pustules. Histopathological examinations (c) showing hyperkeratosis, parakeratosis, regular acanthosis with few neutrophils in stratum corneum (a: H and E, ×200)|
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A 34-year-old female who had psoriatic arthritis with no skin lesions since November 2012 presented to us. She was followed by a rheumatologist and was prescribed 15 mg methotrexate with good control. Later in August 2014, she commenced adalimumab as the disease was not fully controlled on methotrexate alone. Following commencement, psoriatic arthritis was controlled and the patient was followed by a rheumatologist with no skin lesions. On April 2015, the patient presented with multiple pustules on the hands and feet [Figure 2]. A skin biopsy was taken and showed psoriasiform pattern with hyperkeratosis containing neutrophils. Accordingly, the patient was shifted to subcutaneous ustekinumab 45 mg every 3 months and continued on methotrexate 15 mg subcutaneous plus 5 mg of folate weekly. There was no topical treatment used. After 2 months, both skin and joints diseases were well controlled without the need of any other medications. The patient was seen on September 2016 and was still maintaining good improvement.
|Figure 2: Clinical images (a and b) showing multiple hyperkeratotic plaques over both feet with few dried pustules. Histopathological examination (c) showing hyperkeratosis, parakeratosis, regular acanthosis with subcorneal pustules (a: H and E, ×100)|
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| Discussion|| |
The induction or worsening of psoriasis by TNF-α inhibitors has been widely reported recently. The American Food and Drug Administration recently added this adverse event in the prescribing information of TNF-α inhibitors. More than 200 cases have been reported to have this adverse reaction with the incidence rate of approximately 1.04/1000 person per year in patients with RA. A review of psoriasis cases induced or worsened by TNF-α inhibitors use has shown that RA is the most common, followed by seronegative spondyloarthropathy, with inflammatory bowel disease as the least common. In one retrospective study that included 56 patients with TNF-α inhibitor-induced psoriasis, the report showed that Crohn's disease was the most common indication for using TNF-α inhibitors, followed by RA then psoriasis and psoriatic arthritis. In the same study, plaque psoriasis (in 48% of cases) and palmoplantar pustulosis (in 45% of cases) were the most common psoriasis subtypes. In addition, a report by Wollina et al. showed that of the 120 cases, psoriasis (except palmoplantar pustular type) was the most common adverse event during TNF-α inhibitor treatment (61%), followed by palmoplantar pustulosis (31%). There are no predisposing factors that were identified to develop anti-TNF-α-induced psoriasis, with no association between specific agents and psoriasis subtype. However, most of the cases can be managed conservatively with no need to discontinue the agent or changing to another TNF-α inhibitor.
The recommended treatment includes topical corticosteroids and Vitamin D analogs, phototherapy, and systemic agents such as acitretin, methotrexate, and cyclosporine. Choosing the modality of treatment depends on the subtype and severity of the psoriasis.
The TNF-α inhibitor-induced psoriasis pathophysiologic mechanism is unknown with different suggested mechanisms mentioned across the literature. The suggested mechanisms include activation of autoreactive T cells, type 1 interferon production by plasmacytoid dendritic cell precursors, and upregulation of the interleukin-1 (IL-1) family of inflammatory mediators. Despite these proposed mechanisms, the pathogenesis of TNF-α-induced psoriasis remains unclear.
Literature analysis showed that the majority of patients (79%) were able to continue with their original TNF-α inhibitors or a substitute from the same class. Among those who discontinued therapy, most of the cases had complete skin resolution while approximately 25% of the cases had full resolution when they continued with TNF-α inhibitors.
Therefore, patients are better controlled if they are treated by dermatologists with potent topical corticosteroids, keratolytics, Vitamin D analogs, phototherapy, increases in baseline methotrexate doses, and cyclosporine as needed.
In our cases, shifting to IL-12 and IL-23 blockers together with methotrexate or adding methotrexate alone showed good results in controlling the complications. However, the standard treatment for these complications is still unclear and requires further, larger studies.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]