RESEARCH - Psoriatic skin lesions induced by TNF antagonist therapy: a literature review and potential mechanisms of action

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Arthritis Rheum. 2008 Jul 15;59(7):996-1001.

Psoriatic skin lesions induced by tumor necrosis factor antagonist

therapy: a literature review and potential mechanisms of action.

Collamer AN, Guerrero KT, Henning JS, Battafarano DF.

Rheumatology Service, Army Medical Center, Fort Sam Houston,

Texas 78234, USA.

OBJECTIVE: Numerous reports of the induction or worsening of psoriasis

in patients treated with tumor necrosis factor (TNF) antagonists

indicate that this is not a rare phenomenon. The etiology of this

paradoxical clinical response remains unclear. The aim of this study

was to describe similar cases, conduct a comprehensive analysis of the

literature, explore possible immunologic mechanisms of action of this

perplexing reaction, and recommend management options.

METHODS: A systematic literature review was performed using the PubMed

and Medline databases (1996 to September 2007) searching the index

terms " infliximab, " " etanercept, " " adalimumab, " " tumor necrosis factor

alpha inhibitor, " and " TNF inhibitor, " combined with the terms

" psoriasis, " " pustular, " " skin, " " rash, " and " palmoplantar. " All

relevant articles in English were reviewed. Pertinent secondary

references were also analyzed.

RESULTS: According to the literature, new-onset psoriasis may occur

any time after initiation of TNF antagonist therapy, is often of an

uncommon morphology, may respond to psoriasis treatments, and usually

resolves with TNF discontinuation. The pathogenesis of this response

appears to involve a disruption in cytokine balance following TNF

inhibition, resulting in the up-regulation of plasmacytoid dendritic

cells and the subsequent production of unopposed interferon-alpha,

following a triggering event in predisposed individuals.

CONCLUSION: TNF antagonist-induced psoriasis is a newly recognized

adverse effect of these medications that typically does not require

therapy cessation. We recommend aggressive treatment of the skin

disease and consideration of a change in the TNF antagonist if the

lesions are unresponsive to conventional psoriasis treatment.

PMID: 18576309

http://www.ncbi.nlm.nih.gov/pubmed/18576309

Not an MD