DOI: 10.1097/RHU.0b013e318228bcb6
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PMID: 21808187
Issn Print: 1076-1608
Publication Date: 2011/08/01
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Excerpt
Recently, multiple cases of severe psoriasis during infliximab therapy have been reported in the Journal of Clinical Rheumatology.1-3 We add to that experience and report infliximab-induced palmoplantar psoriasis, a surprising adverse effect in a patient with ankylosing spondylitis (AS). Infliximab, a tumor necrosis factor α (TNF-α) antagonist, is highly effective in chronic autoimmune diseases and inflammatory conditions.
A 29-year-old woman was referred to our department with complaints of chronic low-back pain and morning stiffness. Lumbar spine motion was limited in all planes, and Schober test result was 3 cm. Laboratory and radiographic findings included sedimentation rate of 30 mm/hr (0-16), C-reactive protein 2 mg/dL (0-0.3 mg/dL), HLA B27 positive, and bilateral grade 2 sacroiliitis. Bath Ankylosing Spondylitis Disease Activity Index score was calculated as 6.3. Monotherapy with infliximab (5 mg/kg) was started. Clinical complaints were diminished, and improvement in spinal mobility was obtained in a short time. After the fourth infusion, nearly at the fourth month on infliximab therapy, she developed a papulopustular eruption. On dermatology consultation, psoriasis was diagnosed clinically and histologically due to papulopustular and papulosquamous lesions mainly located over the palms and soles and few similar lesions on the trunk of her body (Fig.). She did not have psoriasis before, nor did any person in her family history. Infliximab was discontinued. Oral administration of methotrexate and topical treatment with corticosteroids were initiated. The dosage of methotrexate was 7.5 mg weekly and gradually increased to the dosage of 20 mg weekly. Skin lesions were improved in 2 months. However, the complaints of low-back pain returned, but she did not accept a new treatment plan with a new anti-TNF inhibitor such as adalimumab or etanercept.
Tumor necrosis factor α inhibitors are effective drugs for diseases such as rheumatoid arthritis, AS, Crohn disease, or psoriasis.4-6 Reported cutaneous adverse effects of these drugs are infusion and injection-site reactions, psoriasiform eruptions, lupus-like disorders, vasculitis, granulomatous reactions, cutaneous infections, and cutaneous neoplasms. The most characteristic pattern of psoriasiform eruption associated with TNF-α inhibitors is localized pustular eruption occurring symmetrically on the palms and soles, resembling palmoplantar pustulosis.7 It has been suggested that TNF-α inhibitors promote autoreactivity in general, expression of cutaneous lymphocyte antigen by T cells, and expression of certain chemokine receptors in skin, such as chemokine C-X-C motif receptor 3 (CXCR-3), which promote infiltration of autoreactive T lymphocytes. By this mechanism, TNF-α inhibitors may aggravate the preexisting psoriasis. Psoriasis can also be initiated or aggravated by interferon α. Tumor necrosis factor α and other cytokines trigger abnormal keratinocyte proliferation and differentiation resulting in the clinical features of psoriasis.3,8-10 The potential etiologies for the induction of psoriasis, especially palmoplantar psoriasis, such as inflammation triggered by suppression of TNF-α in eccrine gland epithelium, activation of infections, reactivation of persistent obligate intracellular bacteria, and smoking, have been suggested.8 Patients presenting with skin lesions resembling psoriasis should be evaluated for possible viral or bacterial infection. Possible mechanical stressors, trauma, and emotional status that can trigger psoriasis should be identified. All patients should be referred to a dermatologist for evaluation and biopsy to support the diagnosis of psoriasis. Angelıque et al.11 recommended that patients who feel their psoriasis lesions are tolerable, despite their skin disease, should be offered an alternative TNF antagonist. Management should be regulated according to the type and size of lesions. Lesions of less than 5% of total body surface should be treated with topical treatments. If they are covering more than 5% of body surface area and include palmoplantar pustular disease, ultraviolet phototherapy and methotrexate, acitretin, and cyclosporine should be considered.
