242
Management of anti-TNF psoriasiform lesions generally does not require ces-
sation of anti-TNF agent [ 36 ]. For mild disease with lesions encompassing less
than 5% of total body surface area, the anti-TNF agent can be continued [ 31 , 33 ,
36 ]. Treatments of mild psoriasiform lesions include topical corticosteroid, emol-
lients, keratolytic therapy, vitamin D analogs, and/or ultraviolet phototherapy [ 31 ,
33 , 36 ]. In the case series of Guerra et al., 17/21 patients (81%) continued the anti-
TNF agent and had resolution of psoriasiform lesions using topical corticosteroid
with or without ultraviolet phototherapy [ 31 ]. Duration of therapy before response
typically ranges from 1 to 3 weeks [ 31 ]. In a systematic review consisting of 222
cases of anti-TNF-related psoriatic lesions, Denadai et al. found that 64/87 (74%)
had resolution of psoriatic skin lesions without having to withdraw the anti-TNF
agent [ 33 ].
In refractory disease or in cases of severe disease with greater than 5% of total
body surface area involved, discontinuation of anti-TNF agent may be necessary
[ 31 , 33 , 36 ]. In a retrospective study consisting of 85 patients (69 with CD, 15 with
UC, and 1 with indeterminate colitis), 29 (34%) patients discontinued anti-TNF
therapy due to uncontrolled skin lesions [ 25 ]. In a review published by Denadai
et al., 86 patients had their anti-TNF agent discontinued, and a large number of
these patients, 71/86 (83%), subsequently had resolution of their skin lesions [ 33 ].
In addition to topical therapies and phototherapy as described above, systemic
treatments such as retinoids, methotrexate, or cyclosporine may also be necessary in
these complicated cases [ 31 , 33 , 36 ].
Recurrence of psoriasiform lesions can occur after reinitiating or switching
anti- TNF therapy [ 27 , 31 , 33 ]. In the case series by Guerra, 4/21 (19%) patients
had their anti-TNF therapy discontinued: One patient had complete response
after discontinuation and no recurrence of psoriasis after reintroduction of the
same anti-TNF therapy. The other three patients had partial response after dis-
continuation of the drug (two patients had discontinued anti-TNF therapy perma-
nently; the third patient who had palmoplantar psoriasis was managed with
topical corticosteroid and then had mild recurrence after anti-TNF therapy was
reintroduced, and the psoriasiform lesions were successfully controlled with top-
ical corticosteroid) [ 31 ]. In a single- center observational retrospective study,
59/583 (10.1%) IBD patients had psoriasiform lesions emerge on anti-TNF ther-
apy [ 27 ]. Twenty-one of 59 patients (35.6%) switched to another anti-TNF ther-
apy and over half of these patients (12/21, 57%) had recurrence of psoriasiform
lesions [ 27 ]. Similarly, in the review published by Denadai et al., of the 29
patients who switched anti-TNF agents, 21 (72%) had recurrence or aggravation
of their psoriasiform lesions [ 33 ].
Early recognition and prompt initiation of therapy is essential in management of
anti-TNF-associated psoriasiform lesions. Except in cases where the psoriasiform
lesion is severe or extensive, topical treatment is the therapy of choice, and discon-
tinuation of the biologic agent may not be necessary. Patients who are rechallenged
with the same or a different anti-TNF agent need to be monitored closely as recur-
rence of psoriasiform lesions frequently occur (see Table 14.3) [ 33 ].
U. Wong and R.K. Cross