Jashin J. Wu (ed.)Clinical Cases in PsoriasisClinical Cases in Dermatology10.1007/978-3-319-52779-6_11

11. 62-Year-Old Male with Rash Induced by Tumor Necrosis Factor Inhibitor

Mina Amin¹, Daniel J. No² and Jashin J. Wu³

(1)

University of California, Riverside School of Medicine, Riverside, CA, USA

(2)

Loma Linda University School of Medicine, Loma Linda, CA, USA

(3)

Wu Medical Associates, Inc., Los Angeles, CA, USA

Jashin J. Wu

Email: jashinwu@gmail.com

Keywords

PsoriasisTNF inhibitorInfliximabAdalimumabEtanerceptCorticosteroidMethotrexate

A 62-year-old male with a history of Crohn’s disease and ankylosing spondylitis presented to the clinic with a 3-week history of new-onset pruritic erythematous scaly papules on bilateral upper extremities. The patient stated that the rash had started on the dorsal aspect of his hands and progressively extended to his forearms, elbows, and axillae. The patient had tried applying emollients to the lesions with no benefit. He denies fever, chills, unintentional weight loss, and recent travel. The patient has no known allergies and denies the recent use of new medications. He has been using infliximab for 2 years for the management of Crohn’s disease and ankylosing spondylitis. He denies a family history of skin disorders.

On physical examination, there were multiple scattered 1 cm erythematous papules with fine white scales on the plantar and dorsal aspects of both hands. A few lesions were extending up to bilateral forearms. There were also 2–3 cm erythematous well-demarcated plaques with thicker white scales on bilateral elbows and axillae.

Based on the clinical case description, what is the most likely diagnosis?

1.

Seborrheic dermatitis
2.

Atopic dermatitis
3.

Nummular eczema
4.

Psoriasis secondary to TNF inhibitor therapy
5.

Acute generalized exanthematous pustulosis

Diagnosis

Psoriasis secondary to TNF inhibitor therapy

Discussion

Tumor necrosis factor alpha (TNF-alpha) is a proinflammatory cytokine that plays an important role in the development of a variety of inflammatory disorders. TNF inhibitors are widely used to treat rheumatoid arthritis, inflammatory bowel disease, spondyloarthropathies, and even psoriasis. Multiple reports have described a paradoxical exacerbation of preexistent psoriasis or de novo psoriasis in patients on TNF inhibitor therapy (López-Robles et al. 2012; Wollina et al. 2008).

Infliximab, adalimumab, and etanercept are all associated with development or aggravation of psoriasis (Famenini and Wu 2013). A comprehensive literature review of 142 cases reveals the onset of psoriasis to occur 13.6, 7.6, and 8.2 months after initiation of infliximab, adalimumab, and etanercept, respectively (Famenini and Wu 2013). Palmoplantar pustular psoriasis and pustular psoriasis are rare forms of psoriasis. However, these are the most common types of psoriasis that develop in patients on TNF inhibitor therapy. Patients with inflammatory bowel disease are more likely to develop psoriasis with infliximab therapy. Alternatively, patients with rheumatologic diseases are more likely to develop psoriasis on adalimumab. Additionally, women are at a slightly higher risk than men to develop psoriasis on TNF inhibitor therapy (Famenini and Wu 2013).

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