Paradoxical psoriasiform inflammatory reaction during the use of tumor necrosis factor-alpha inhibitors in patients with Crohn’s disease (a review of the literature and presentation of two clinical cases)

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Psoriasiform rash  (paradoxical  inflammation)  induced  by tumor  necrosis  factor-alpha  (TNFα) inhibitors  is observed  in about  5–10% of patients with  inflammatory   bowel   diseases   treated  by these  genetically  engineered agents. Its predictors include gender  (mostly female), smoking, higher  body  mass  index,  and  formation  of anti-neutrophil  antibodies. There is no  correlation between the paradoxical inflammation and specific agent; the rash can develop with the use of any TNFα inhibitor, such as infliximab, adalimumab, or certolizumab  pegol. The first line of treatment for pharmacologically induced psoriasis includes topical corticosteroids  (mostly, high potency  agents clobetasol  and betamethasone) and combination steroid-containing  agents   (betamethasone + calcipotriol). If this treatment is ineffective or the rash recurs during the use of TNFα inhibitors, the rash is qualified as a class-specific effect, with consideration of switching the patient  to a genetically engineered  product  with another  mechanism  of action. In such a case, there is a strong indication for ustekinumab. Despite a relatively high incidence of the paradoxical inflammation with TNFα inhibitors and a bulk of published data, some questions remain unanswered. In particular, further studiesare required  into the  time intervals between the achievement  of  a  clinically significant  effect  of TNFα inhibitors on the symptoms of inflammatory bowel diseases and the skin rash formation, which means the possibility of treatment withdrawal and change  of the treatment strategy, as well as studies on the long-term prognosis of the skin lesions. In this context, clinical case presentation and the accumulated experience would subsequently help to formulate  actual clinical recommendations on the management of this patient category.

About the authors

L. S. Kruglova

Central State Medical Academy of Department of Presidential Affairs

Author for correspondence.

Larisa S. Kruglova – MD, PhD, Head of Chair of Dermatovenereology and Cosmetology.

19–1А Marshalа Timoshenko ul., Moscow, 121359.

Tel.: +7 (916) 705 69 07. 

Russian Federation

O. B. Shchukina

Academician I.P. Pavlov First St. Petersburg State Medical University


Oksana B. Shchukina – MD, PhD, Research Advisor of the Municipal Center for Diagnostics and treatment of inflammatory bowel diseases, Municipal Clinical Hospital # 31.

6–8 L'va Tolstogo ul., Saint Petersburg, 197022.

Russian Federation


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Copyright (c) 2018 Kruglova L.S., Shchukina O.B.

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