title: Psoriasiform Skin Lesions Are Caused by Anti-TNF Agents Used for the Treatment of Inflammatory Bowel Disease.
abstract: BACKGROUND
  Tumor necrosis factor (TNF) antagonists used for the treatment of inflammatory bowel disease (IBD) have been associated with the development of psoriasiform skin lesions. We assessed the demographic and clinical characteristics associated with and outcomes of patients with anti-TNF-induced psoriasiform lesions.
  
  
  METHODS
  Patients with Crohn's disease (CD) and ulcerative colitis (UC) receiving treatment with anti-TNF therapy (infliximab, adalimumab, or certolizumab pegol) at a tertiary referral center were identified using an IRB-approved clinical data repository. Patients that developed psoriasiform skin lesions after initiation of anti-TNF therapy were included as cases. A group of anti-TNF-treated patients without drug-related psoriasiform lesions were identified as controls. The association between demographic and clinical variables and psoriasiform lesions was assessed using Chi-square analyses and multivariable logistic regression.
  
  
  RESULTS
  Five hundred twenty-one patients with IBD undergoing treatment with anti-TNF therapy were identified; of these, 18 (3.5%) had psoriasiform lesions (16 CD and 2 UC). Seventy-two patients were identified as controls. Lesions developed a mean of 58 weeks (range 4-240 weeks) after starting anti-TNF therapy. The majority of patients were female and Caucasian (63 and 78%, respectively). Thirty-nine percent of patients had upper tract disease location. Forty-five patients (50%) were current or former smokers. Location of psoriasiform lesions included palmo-plantar (53%), trunk (47%), and scalp (53%), with 88% reporting involvement of ≥2 locations. Treatment of psoriasiform lesions was instituted with topical therapy in eight patients and systemic therapy (± phototherapy) in five patients. Discontinuation of anti-TNF therapy was recommended in nine patients (50%); of those, three were retreated with a second anti-TNF agent and all had recurrence of psoriasiform lesions. When adjusted for multiple variables, upper GI tract disease was significantly associated with psoriasiform lesions.
  
  
  CONCLUSIONS
  Anti-TNF-induced psoriasiform lesions developed in 3.5% of patients with IBD at a tertiary referral center. Similar to prior published studies, most patients were female, had involvement of the palmo-plantar and scalp regions, and did not have severe IBD activity. The presence of upper tract disease was associated with the development of psoriasiform lesions. Skin lesions led to discontinuation of anti-TNF therapy in 50% of patients. Based upon these results, IBD providers should educate patients about this adverse effect, refer to dermatology for treatment, and discuss alternative IBD therapeutic options early if a severe psoriasiform rash develops.
authors.affiliation: Department of Medicine, University of Maryland School of Medicine, 100 North Greene Street, Lower Level, Baltimore, MD, 21201, USA.
authors.forename: Lauren A
authors.initials: LA
authors.lastname: George
authors.affiliation: Department of Medicine, University of Maryland School of Medicine, 100 North Greene Street, Lower Level, Baltimore, MD, 21201, USA.
authors.forename: Akash
authors.initials: A
authors.lastname: Gadani
authors.affiliation: Department of Medicine, University of Maryland School of Medicine, 100 North Greene Street, Lower Level, Baltimore, MD, 21201, USA.|Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, MD, USA.
authors.forename: Raymond K
authors.initials: RK
authors.lastname: Cross
authors.affiliation: Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, MD, USA.
authors.forename: Guruprasad
authors.initials: G
authors.lastname: Jambaulikar
authors.affiliation: Department of Medicine, University of Maryland School of Medicine, 100 North Greene Street, Lower Level, Baltimore, MD, 21201, USA. lghazi@medicine.umaryland.edu.|Division of Gastroenterology and Hepatology, University of Maryland, Baltimore, MD, USA. lghazi@medicine.umaryland.edu.|Veterans Affairs, Maryland Health Care System, Baltimore, MD, USA. lghazi@medicine.umaryland.edu.
authors.forename: Leyla J
authors.initials: LJ
authors.lastname: Ghazi
mesh_terms: D000293:Adolescent; D000328:Adult; D000893:Anti-Inflammatory Agents / Q000009:adverse effects*; D001688:Biological Products / Q000009:adverse effects*; D016009:Chi-Square Distribution; D003093:Colitis, Ulcerative / Q000175:diagnosis / Q000188:drug therapy* / Q000276:immunology; D003424:Crohn Disease / Q000175:diagnosis / Q000188:drug therapy* / Q000276:immunology; D003875:Drug Eruptions / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D016017:Odds Ratio; D011565:Psoriasis / Q000139:chemically induced* / Q000175:diagnosis / Q000628:therapy; D012189:Retrospective Studies; D012307:Risk Factors; D062606:Tertiary Care Centers; D013997:Time Factors; D014409:Tumor Necrosis Factor-alpha / Q000037:antagonists & inhibitors*; D055815:Young Adult
chemical_list: D000893:Anti-Inflammatory Agents; D001688:Biological Products; D014409:Tumor Necrosis Factor-alpha
keywords: Anti-TNF; Inflammatory bowel disease; Psoriasiform rash; Tobacco use