General Dermatology

TNF-alpha Inhibitor-Induced Psoriasis: A Decade of Experience

A retrospective chart review of Cleveland Clinic patients with TNFi-psoriasis over a 10-year period identified 102 patients with a mean age of 40 years. A total of 73.5% were female. Crohn’s disease (48%) and rheumatoid arthritis (24.5%) were the most common primary conditions in this cohort. Infliximab (52%) was the most common inciting agent, and the most common psoriasis subtypes occurring were plaque-type (49.5%), scalp (47.5%), and palmoplantar pustulosis (PPP) (41%). Smoking was a significant risk factor for developing PPP (63% PPP vs 16% other subtypes; P < 0.007), and patients with inflammatory bowel disease had a higher risk of developing inverse and scalp psoriasis.

TNF-alpha Inhibitor Associated With Onset of TNFi-Psoriasis (N = 102)

2003 — 2013

Agent Number of Patients (%)
Infliximab 53 (52)
Adalimumab 31 (30)
Etanercept 18 (18)
Certolizumab 0
Golimumab 0

Topical medications alone improved or resolved TNFi-psoriasis in 63.5% of patients, and cyclosporine and methotrexate (> 10 mg weekly) were likely to be effective if topicals failed.

Treatments and Outcomes of Patients Continued on the Inciting TNF-alpha Inhibitor (N = 119)

2003 — 2013

Medications and Outcomes Improved or Resolved Persistent
No rx 0 0
Topicals alone 40 24
Topicals plus other medications 17 8
MTX aloneᵃ 0 1
MTX plus other medicationsᵃ 4 3
Cyclosporine alone 1 0
Cyclosporine plus other medications 3 0
Systemic steroids alone 1 2
Systemic steroids plus other medications 2 2
UV plus others 5 4
Increased dose or frequency 2 (A, I) 0
Totalsᵇ 75 44

MTX = methotrexate, A- Adalimumab, I-Infliximab

ᵃDoes not include patients concomitantly treated with methotrexate at onset of TNF-alpha inhibitor-induced psoriasis.
ᵇNumbers add up to 130, which represent the number of all treatments and outcomes for 102 patients. Some patients had more than one treatment regimen (secondary to incomplete or poor response to previous treatment).

Discontinuation of the inciting TNF-alpha inhibitor agent with or without other interventions improved or resolved psoriatic lesions in 67% of cases, while switching to another TNF-alpha inhibitor resulted in persistence or recurrence of psoriasis in 64%.

Outcome of TNF-alpha-Induced Psoriasis After Switching Biologic Agents (N = 33)

2003 — 2013

Biologic Attempted After Onset of TNF-Psoriasis Improved or Resolved Persistent
Infliximab 0 0
Adalimumab 7 7
Etanercept 1 5
Certolizumab 1 3
Golimumab 0 1
Ustekinumab 3 1
Abatacept 3 1
Totals 15 18

Other treatments may have been tried before attempting to switch biologics for some patients.

Topical medications represent the most reasonable first-line treatment. For patients who do not respond, treatment with methotrexate or cyclosporine represents a good second-line option. For refractory patients, switching TNF-alpha inhibitors or switching to biologics that have alternative mechanisms of action is the best option.