TNF-α inhibitor–induced psoriasis: A decade of experience at the Cleveland Clinic

Published:December 18, 2018DOI:https://doi.org/10.1016/j.jaad.2018.12.018

      Background

      Tumor necrosis factor-α (TNF-α) inhibitor (TNFI)-induced psoriasis remains poorly understood despite having been described 15 years ago. As TNFIs often provide life-changing patient benefits, understanding effective treatments for TNFI-induced psoriasis is important.

      Objective

      We characterized a cohort of patients with TNFI-induced psoriasis whose psoriasis was specifically diagnosed and managed or comanaged by dermatologists at a single tertiary care institution over a 10-year period.

      Methods

      Retrospective review of patients in whom TNFI-induced psoriasis was diagnosed between 2003 and 2013.

      Results

      A total of 102 patients with TNFI-induced psoriasis were identified. The mean age of onset was 40 years, and there was a female predominance (73.5%). Crohn's disease (in 48% of cases) and rheumatoid arthritis (in 24.5% of cases) were the most common primary conditions. Infliximab (in 52% of cases) was the most common inciting agent. The most common TNFI-induced psoriasis subtypes were plaque-type psoriasis (49.5%), scalp psoriasis (47.5%), and palmoplantar pustulosis (41%). Topical medications alone improved or resolved TNFI-induced psoriasis in 63.5% of patients, and cyclosporine and methotrexate (>10 mg weekly) were often effective if topicals failed. Discontinuation of the inciting TNFI with or without other interventions improved or resolved TNFI-induced psoriasis in 67% of refractory cases, whereas switching TNFIs resulted in persistence or recurrence in 64%.

      Limitations

      Retrospective nature of the study and the fact that some patients may have developed typical psoriasis unresponsive to TNFIs.

      Conclusion

      Our study cohort represents the largest single-institution cohort of patients with TNFI-induced psoriasis diagnosed and managed or comanaged by dermatologists to date. On the basis of our findings, we propose a treatment algorithm for TNFI-induced psoriasis.

      Key words

      Abbreviations used:

      IBD ( inflammatory bowel disease), PPP ( palmoplantar pustulosis), PsA ( psoriatic arthritis), PsV ( psoriasis vulgaris), RA ( rheumatoid arthritis), TNFI ( TNF-α inhibitor)
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