When the Treatment Causes Trouble: Understanding Paradoxical Skin Reactions to Infliximab
"Discover how infliximab, a key drug for inflammatory conditions, can sometimes trigger unexpected skin issues, and what you can do about it."
Infliximab, part of the anti-TNF-α drug family, has transformed the management of inflammatory bowel disease (IBD), offering relief to those with ulcerative colitis and Crohn's disease. These medications work by suppressing the tumor necrosis factor (TNF), a key player in inflammation. However, an intriguing twist has emerged: anti-TNF therapies can sometimes trigger inflammatory skin lesions.
These skin reactions, including psoriasis-like eruptions, eczematous conditions, and lupus-like symptoms, are termed "paradoxical" because anti-TNF drugs are often used to treat these very skin conditions. Recognizing these reactions is crucial for dermatologists and patients alike.
This article delves into a specific case of inverted psoriasis triggered by infliximab used in a patient for inflammatory bowel disease. By exploring this case, we aim to shed light on this unexpected side effect, its diagnosis, and management strategies.
Infliximab and Paradoxical Psoriasis: The Case Explained
A 56-year-old woman with a decade-long history of Crohn's disease, affecting multiple areas of her digestive system, was referred for evaluation of a desquamation involving her face, neck and scalp. Initially treated with mesalazine, azathioprine and adalimumabe, her treatment shifted to infliximab to better manage her Crohn's. While infliximab initially controlled her IBD symptoms, an unexpected issue arose two years after starting the treatment.
- The initial diagnostic hypotheses included contact dermatitis, atopic dermatitis, seborrheic dermatitis, and inverse psoriasis.
- A skin biopsy revealed psoriasiform hyperplasia with marked parakeratosis, spongiosis exocytosis, and a superficial inflammatory infiltrate containing lymphocytes, eosinophils and necrotic keratinocytes.
- Based on the clinical, histopathological findings, and the history of infliximab therapy, a diagnosis of paradoxical skin reaction, inverse psoriasis-like, was made.
Navigating Paradoxical Reactions: What You Need to Know
Paradoxical psoriasis induced by anti-TNF-α treatments was first reported in 2004. These side effects are defined as "paradoxical" because anti-TNF-α drugs are commonly used to treat psoriasis. The onset can range from a few days to many months after starting the medication. Risk factors include being female, having Crohn's disease, a personal or family history of inflammatory skin diseases and treatment with adalimumab.
Diagnosing these reactions can be challenging. It's crucial to consider that the eruption may be a paradoxical reaction to infliximab, especially if the patient experiences severe itchiness, resembles inverse psoriasis, and doesn't respond to typical treatments like topical corticosteroids and low-dose oral prednisone. A skin biopsy can help confirm the diagnosis, revealing a spongiotic and psoriasiform dermatitis.
If you develop psoriasis-like lesions while on infliximab, a dermatology evaluation with a biopsy is essential. Management may involve switching to a different anti-TNF-α drug or an immunosuppressant. Discontinuing the anti-TNF drug and starting systemic psoriasis medication can lead to higher cure rates. Awareness of these potential reactions is crucial for both patients and clinicians to ensure timely diagnosis and appropriate management, improving the overall quality of life for individuals undergoing anti-TNF therapy.