Background/Purpose:

Anti TNF therapy’s efficacy in controlling cutaneous psoriasis has widely been proven, but development of paradoxical psoriasis (PPs) as a side effect can occur. We define psoriasis as a paradoxical effect when it appears as new onset or as a different type of psoriatic lesion; some authors also include worsening of previous psoriasis, when it is clearly related with the treatment.

Methods:

We reviewed the medical records from the 371 patients visited in the biological therapy monographic unit and from 150 pateients visited in the psoriatic arthropathy multidisciplinar clinic during 2011 and 2012. We selected 13 patients with suspected paradoxical psoriasis and we analyze clinical data, characteristics and severity of skin lesion, and the change in treatment required to control skin lesion

Results:

  From the 13 selected patients , two presented flares of their skin lesions related to the underlying diagnosis of PsA with severe cutaneous disease prior to biological treatment. Therefore, 11 patients fulfilled the previously exposed criteria for PPs; six female and 5 male, mean aged 47 years (from 34 to 78). 7 patients had had no previous psoriatic lesions: 5 were diagnosed with ankylosing spondylitis (one negative HLA B27), one with rheumatoid arthritis and one with juvenile idiopathic arthritis (an adult patient). The remaining 4 patients were mixed forms of PsA, 3 of them had positive HLA B27.

The treatment involved was adalimumab in 7 patients, infliximab in two patients, and etanercept in the remaining two. PPs appeared between 2 and 38 months from the start of the biological therapy (mean 9 months), in 8 patients  during the first year of the treatment. 

PPs in two patients consisted of desquamative annular lesions that were confirmed by skin biopsy procedure. 7 patients had palmoplantar pustulosis, 4 presented skinfold psoriasis, 4 had scalp lesions, and 6 plaque psoriasis. 7 presented a mixture of different types of cutaneous psoriatic lesions. 

The injury was considered mild in 4 cases managed with topical corticosteroid treatment,  and moderate to severe in six patients that had to discontinue biologic therapy . Another one needed tapering of  the dose of etanercept from 50 to 25 mgs per week. After discontinuation, 4 patients needed a new biological drug (three antiTNF and one ustekinumab), with no cutaneous complication.  Skin evolution was satisfactory to improvement in all cases, with practical resolution in two.

Conclusion:

Paradoxical psoriasis is a rare complication appearing in less than 3% of our patients under biological therapy. Although it can occur in patients with any diagnosis and receiving any kind of antiTNF drug, we find it more frequently in those patients with spondyloarthropaties during the first year of treatment with monoclonal antibodies. It may be an important and disabling side effect, but withdrawal of the biological drug is not always needed. Switching to another antiTNF when needed seems also a safe therapeutic decision with satisfactory outcomes.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/paradoxical-psoriasis-experience-of-a-biological-therapy-monographic-unit/