Biologic Therapy for Psoriasis: Paradoxical Reactivation of Psoriasis on Infliximab

• Infliximab is an anti-TNF biologic
• It is used in the treatment of rheumatoid arthritis, psoriasis and inflammatory bowel disease

A case report from Spain:

• 32 year old female known for Crohn’s disease
• no response to mesalazine and systemic corticosteroids
• was subsequently put on infliximab at a dosage 5mg/kg for a duration of 10 years
• she developed severe psoriasiform plaques covering entire scalp accompanied with alopecia
• biopsy confirmed diagnosis of psoriasis
• The patient improved with topical steroids, vitamin D analogues and methotrexate 15mg subcutaneously weekly. Anti-TNF treatment was stopped.

Discussion

• there are currently over 200 cases of suspected TNF antagonist induced or exacerbated cases of psoriasis in the literature.
• In this case, reactivation was after 10 years of treatment. The cause is unknown but on suggested mechanisms include:
  • the activation of nascent autoreactive T-cells
  • disruption in cytokine balance by TNF blockade, allowing unopposed interferon-alpha production by plasmacytoid dendritic cells in genetically predisposed individuals
• there are currently no guidelines on how to change treatments in this situation.

Contributors

Dr Christophe Hsu – dermatologist. Geneva, Switzerland

Source of information: p317 Development of severe scalp psoriasis and alopecia during treatment of Crohn’s disease with infliximab: a paradoxical side effect. Martinez Peinado C. et al. EADV Annual Meeting (2014), Amsterdam The Netherlands