Journal Scan / Research · July 16, 2022 Predictors of Severity in Paradoxical Psoriasis Due to Biologic Therapies Journal of the American Academy of Dermatology

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• This systematic review of 303 reported cases of paradoxical psoriasis following therapy with a tumor necrosis factor (TNF)-α inhibitor found that the risk of severe paradoxical psoriasis associated with the use of adalimumab was higher than the risk associated with the use of any other TNF-α inhibitor. Patients with paradoxical psoriasis were mostly being treated for inflammatory arthritis or inflammatory bowel disease. Paradoxical psoriasis was more likely to occur in older patients.

• Paradoxical psoriasis severity is associated with the use of adalimumab and is more common in older patients.

–  Kelly B. Scarberry, MD

Written by

 

 

Dawn Davis MD

Biologic therapies are an increasingly common second- or third-line therapy for the treatment of inflammatory disorders, including psoriasis, inflammatory bowel disease, and rheumatoid arthritis, amongst others. With expanding use across patient populations, paradoxical psoriasis is becoming a readily recognized side effect of therapy, occurring in approximately 2–5% of patients. 

Paradoxical psoriasis can be distinguished from psoriasis vulgaris by the presence of pustulosis, prominent scalp involvement (often with significant and bothersome alopecia), or generalized disease (including erythroderma). While the mechanism is unknown, it is postulated a pleomorphic interferon response, may be the etiology.

Croitoru and colleagues reviewed 303 studies by meta-regression and found adalimumab was more commonly associated with paradoxical psoriasis compared to etanercept and all TNF alpha inhibitors combined, despite infliximab being the most common drug prescribed for this patient population. Adalimumab also had the highest likelihood of causing a severe reaction, especially in inflammatory arthritis patients, although patients with psoriasis were also at risk. Advancing age was a protective factor against severe reactions, presumably due to immunosenescence.

It is helpful to inform patients of this potential side effect of biologic therapy, particularly in susceptible populations. It can be confusing to the patient with psoriasis that the chosen treatment may cause an alternative form of psoriasis, or a psoriasiform eruption. If paradoxical psoriasis occurs, it is suggested to trial topical therapies first, adjusting systemic medications thereafter, if necessary.

Abstract

Paradoxical psoriasis occurs in 2% to 5% of those receiving tumor necrosis factor-α therapy for preexisting psoriasis, inflammatory bowel disease, and inflammatory arthritis. This is thought to represent a pleomorphic interferon response, but the risk factors are poorly understood. We conducted a systematic review of paradoxical psoriasis from biologics used in the treatment of psoriasis and its associated inflammatory diseases to identify associations with severe reactions.

Journal of the American Academy of Dermatology

Predictors of Severity in Paradoxical Psoriasis from Biologic Therapies: A Systematic Review

J Am Acad Dermatol 2022 Jun 16;[EPub Ahead of Print], DO Croitoru, SG Brooks, N Nathanielsz, O Silverberg, I Nicolau, AM Drucker, M Silverberg, J Yeung, JJ Limacher, V Piguet 

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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