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TNF Inhibitor-Induced Psoriasis

TNF blocker Induced Psoriasis: Take Home Messages

  • Incidence: Roughly 1 per 1000 pt-yrs
  • Observed with all TNF inhibitors and all indications
  • Pustular lesions seen in nearly 50%
  • Topical steroids effective in 25-40%
  • TNFi withdrawal effective in 60-75%
  • TNFi switching effective in only 15%

Four of the five currently marketed TNF inhibitors have chronic moderate-to-severe plaque psoriasis as an indication. The efficacy of this TNFi therapy in psoriasis has been obfuscated by hundreds of cases of new onset psoriasis in patients receiving anti-TNF therapy.

TNF-induced psoriasis has been been reported in adults and children with rheumatoid arthritis, spondyloarthritis, psoriasis and Crohn's more so than ulcerative colitis (1-4). The etiology of this event is unknown.

Several studies have addressed the frequency and presentations of this phenomenon. Harrison et al examined the frequency of de novo psoriasis among the 9826 TNFi and 2880 DMARD treated RA patients in the British Society of Rheumatology Biologics Registry between January 2001 – July 2007(2). They found 25 new onset psoriasis patients on TNFi, but none amongst those treated with DMARD therapy. They estimate the frequency of this adverse event be 1 per 1000 person-years of TNFi exposure. Most had more severe psoriasis or palmoplantar pustulosis and those who discontinued the TNFi, 75% showed improvement.

Interestingly, 40-50% have presented as pustular psoriasis or palmoplantar pustulosis. Plaque psoriasis is less frequent (20-40%), with fewer cases of either scalp or erythrodermic psoriasis. Worsening of psoriasis and/or new onset palmoplantar pustulosis has been reported in patients under treatment for chronic plaque-type psoriasis (5).

The FDA alerted clinicians in 2009 by detailing 69 cases of new onset psoriasis (from the Adverse Event Reporting system), including 17 pustular and 15 palmoplantar cases, in patients using TNF blockers for treatment of autoimmune and rheumatic conditions other than psoriasis and psoriatic arthritis. Hospitalization was reported in 12/69 cases.

A retrospective report of TNFi treated patients (1998-2010) from the Mayo Clinic identified 56 patients who developed psoriasis when treated for Crohn's disease (39%) or RA (25%). Psoriasis occurred a mean of 17.1 months after TNFi initiation. And a variety of presentations were seen: plaque psoriasis (27), palmoplantar pustulosis (25), scalp psoriasis (12), generalized pustular psoriasis (7), erythrodermic psoriasis (2) or inverse psoriasis (2).

New psoriasis occurring in 30 TNFi-treated IBD patients were reported by Cullen et al; 80% having Crohn's and 20% with ulcerative colitis (4). 70% were well controlled and one-third were receiving MTX or azathioprine. Two-thirds had a good response to topical corticosteroids and most of these continued the same or alternate TNFi. For those not responding to topical therapy, 2/3 ultimately stopped TNFi therapy. They identified an additional 120 IBD patients with TNFi related psoriasis and found that 41% responded favorably to topical therapy. TNFi switching occurred in 27/148 patients, but this was only successful in 15%. Overall 43% had to discontinue TNFi therapy due to psoriasis.

While Harrison and Cullen indicate a median time to onset of 5-6 months, Ko suggests a mean onset of 10.5 months and there are reports occurring 2-9 years after beginning therapy (1,3,4).
Management of anti-TNF drug-induced psoriasis is empiric at best. The FDA report states that a majority of patients experienced improvement of their psoriasis following discontinuation of the TNF blocker. While some series suggest that 60-75% will improve their psoriasis with TNFi discontinuation, it appears that one-third improve with continued use (with or without topical steroid) or change in TNF blocker. Cullen and Ko suggest that only 15% will respond to TNFi switching alone and 25-40% will respond to topical corticosteroids. For those with palmoplantar pustulosis or severe psoriasis, discontinuation of the TNF inhibitor is advised.

References
1. Harrison MJ et al. Ann Rheum Dis. 2009;68:209-15. (PMID:18385277)
2. FDA Alert (8/4/09) http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPa...
3. Shmidt E, J Am Acad Dermatol Jul 2011 (PMID:21752492)
4. Cullen G, et al. Aliment Pharmacol Ther. 2011; 34:1318-27 (PMID:21957906)
5. Ko JM, et al. J Dermatolog Treat. 2009;20:100-8 (PMID:18923992)
6. Mössner R, et al. Arch Dermatol Res. 2008;300:101 (PMID:18239925)

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Disclosures
The author has no conflicts of interest to disclose related to this subject