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- Title
Paradoxical Psoriasiform Eruptions in Children Receiving Tumor Necrosis Factor α Inhibitors.
- Authors
Eickstaedt, Joshua; Paller, Amy S.; Lund, Emily; Murphrey, Morgan; Brandling-Bennett, Heather; Maurano, Megan; Fernandez Faith, Esteban; Holland, Kristen E.; Ibler, Erin; Liang, Marilyn G.; Todd, Patricia S.; Siegfried, Elaine; Igelman, Sean; Cordoro, Kelly M.; Tollefson, Megha M.
- Abstract
Key Points: Question: What are the clinical features and clinical course of tumor necrosis factor α (TNF) inhibitor–induced psoriasiform eruptions in children? Findings: In this multicenter cohort study of 103 pediatric patients with TNF inhibitor–induced psoriasiform dermatitis associated with infliximab, adalimumab, and/or certolizumab pegol, inflammatory bowel disease (91%) was the most common indication for TNF inhibitor therapy. With the use of skin-directed therapies alone, 85 patients (83%) were able to continue initial or second-line TNF inhibitors. Meaning: The results of this study suggest that most pediatric patients who develop TNF inhibitor–induced psoriasiform eruptions are able to continue taking the TNF inhibitor, facilitated by the use of adjuvant therapies for the skin eruption. Importance: Tumor necrosis factor α (TNF) inhibitor–induced psoriasiform eruption is well recognized in adults, but few reports document this paradoxical effect in children. Objective: To characterize the clinical features and the clinical time course of TNF inhibitor–induced psoriasiform eruptions in children. Design, Setting, and Participants: A multicenter retrospective case series of children younger than 18 years seen between January 1, 2000, and December 31, 2016, who developed a new-onset psoriasiform eruption while taking a TNF inhibitor for a nondermatologic disorder. Participating sites were members of the Pediatric Dermatology Research Alliance. Data were entered into a Research Electronic Data Capture database at the Mayo Clinic (ie, the coordinating center). Results: Psoriasiform eruptions were identified in 103 TNF inhibitor–treated patients (median age, 13.8 years [IQR, 11.7-16.4 years]; 52 female patients [50%]; 57 White patients [55%]), with 67 patients (65%) treated with infliximab, 35 (34%) with adalimumab, and 1 (1%) with certolizumab pegol. Most patients had no personal history (101 [98%]) or family history of psoriasis (60 patients [58%]). Inflammatory bowel disease was the most common indication for treatment with TNF inhibitor (94 patients [91%]). The primary extracutaneous disease was under control in 95 patients (92%) who developed the eruption. Most patients (n = 85 [83%]) developed psoriasiform eruptions at multiple anatomic sites, with scalp involvement being most common (65 patients [63%]). Skin disease developed at a median of 14.5 months (IQR, 9-24 months) after TNF inhibitor initiation. To treat the psoriasiform eruption, topical steroidal and nonsteroidal medication was prescribed for all patients. Systemic therapy was added for 30 patients (29%): methotrexate for 24 patients (23%), oral corticosteroids for 8 patients (8%), and azathioprine for 1 patient (1%). For 26 patients (25%), suboptimal effectiveness with topical medications alone prompted discontinuation of the initial TNF inhibitor and a change to a second-line TNF inhibitor with cutaneous improvement in 23 patients (88%) by a median of 3 months (IQR, 2-4 months). Eight patients (31%) who started a second-line TNF inhibitor developed a subsequent TNF inhibitor–induced psoriasiform eruption at a median of 6 months (IQR, 4-8 months). Persistent skin disease in 18 patients (17%) prompted discontinuation of all TNF inhibitors; 11 patients changed to a non-TNF inhibitor systemic therapy, and 7 discontinued all systemic therapy. Conclusions and Relevance: In this case series, paradoxical TNF inhibitor–induced psoriasiform eruptions were seen in children treated with TNF inhibitors for any indication, and there appears to be a class effect among the varying TNF inhibitors. The majority of these children were able to continue TNF inhibitor therapy with adequate skin-directed and other adjuvant therapies. This case series characterizes the clinical features and the clinical time course of TNF inhibitor–induced psoriasiform eruptions in children.
- Publication
JAMA Dermatology, 2023, Vol 159, Issue 6, p637
- ISSN
2168-6068
- Publication type
Article
- DOI
10.1001/jamadermatol.2023.0549