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.
Recognized Clinical Impact
Paradoxical skin reactions to infliximab have been reported in real-life case studies and clinical trials despite the drug's overall acceptable safety profile. Reported presentations include new-onset psoriasis vulgaris in a patient with Crohn's disease and paradoxical pustular psoriasis in a patient receiving infliximab for psoriasis vulgaris. Diagnosing paradoxical pustular psoriasis during TNF-alpha treatment can be considerably challenging.
From Side Effect to Defined Reaction
Paradoxical psoriasis is described as a drug side effect involving red, scaly, psoriasiform plaques during treatment with TNF-alpha inhibitors. These inhibitors are used for autoimmune conditions including inflammatory bowel disease, rheumatoid arthritis, and psoriasis. DermNet reports that studies show 2% to 5% of patients receiving TNF-alpha inhibitors may develop paradoxical psoriasis, with higher incidence among women and smokers or ex-smokers, although the absolute risk remains low.
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.
Early Recognition and Treatment Change
A January 26, 2026 case report highlights the importance of early monitoring for paradoxical reactions after initiating tumor necrosis factor-alpha inhibitor therapy in patients with severe psoriasis. The report also emphasizes transitioning to an alternative biologic class when effective management requires a change in treatment. Its conclusion is based on a reported case rather than a general treatment rule.
An Atypical Treatment Outcome
A case report describes inverted psoriasis developing during infliximab treatment for inflammatory bowel disease. This presentation represents a treatment-associated skin reaction in an atypical, or inverted, psoriasis pattern. Because the source describes a single case, it does not establish how often this outcome occurs or how broadly it applies.
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.
Diagnosis and Timely Intervention
Reports describe new-onset psoriasis occurring paradoxically after TNF-alpha antagonist therapy. One reported case involved erythroderma associated with alopecia that developed during infliximab therapy and produced a positive lymphocyte transformation test result. The report emphasizes that exact diagnosis and early treatment intervention are necessary in cases of this kind.
A Patient-Level Treatment Challenge
A case report describes inverted psoriasis associated with infliximab used to treat inflammatory bowel disease. The report illustrates how a therapy intended to manage an underlying condition can be accompanied by a different and clinically meaningful skin manifestation. As a single case, it documents an individual treatment experience rather than the frequency of this reaction across all patients.
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.