TNF blockers may trigger skin lesions in some patients

Allison Gandey

March 09, 2006

Mar 9, 2006

(Source: Gesundheit.de)

Berlin, Germany - Researchers are hypothesizing that tumor-necrosis-factor (TNF) blockade may have the unexpected effect of prompting new-onset psoriasis or aggravating existing disease [ 1 ]. Despite previous evidence suggesting that TNF inhibitors significantly reduce psoriatic skin lesions, senior author Dr Gerd-R ¿ diger Burmester (Charit¿-University Medicine, Berlin, Germany) and colleagues have published new preliminary findings suggesting that the opposite may be true for some patients. Their work appears in the March 2006 issue of the Annals of the Rheumatic Diseases.

In a small case report, the researchers describe nine patients with rheumatoid arthritis (RA) treated with different types of TNF antagonists who unexpectedly developed psoriatic skin lesions. "The inhibition of TNF-   [may have] influenced the manifestation of psoriasis skin lesions in our patients," write the researchers, led by Dr Sonja Kary (Charit¿-University Medicine). "As far as we know, this is the first demonstration of either a new onset or an exacerbation of psoriatic skin lesions during anti-TNF-  treatment."



Dr Gerd-R¿diger Burmester (Source: Charit¿-University Medicine)



The researchers report that an additional literature search revealed sporadic information on psoriasis and psoriasislike symptoms in patients treated with TNF blockers for inflammatory bowel disease, ankylosing spondylitis, and RA.

They found that withdrawal or dose reduction of TNF-blocking agents led to improvement only in some patients and was generally limited by the activity of the underlying RA. A change within the substance class reduced the severity of the symptoms in some patients, but the researchers found that they could not predict which biological agent would prove to be less harmful.

They looked at two monoclonal antibodies? infliximab (Remicade, Centocor) and adalimumab (Humira, Abbott)?as well as the receptor construct etanercept (Enbrel, Amgen/Wyeth). They note that all three TNF blockers have been shown to be effective in psoriatic skin disease in clinical trials and etanercept in particular has been approved for this indication.

Treatment and type of psoriasis in nine RA patients on TNF-   antagonists

Case
RF
Anticyclic citrullinated peptide antibodies
TNF-    antagonists
Latency (mo)
Psoriasis type
Histology
New onset
Family history
1
+
+
ADA *, ETA, INF, ETA
14
Vulgaris
Yes
Yes
No
2
+
+
ETA *
1
Pustulosa
Yes
Exacerbation
No
3
+
+
ETA, ADA *
4 d
Vulgaris
Yes
Yes
No
4
+
NA
INF *
2
Vulgaris
No
Exacerbation
Sister
5
+
+
ADA *
5
Pustulosa
Yes
Yes
Brother
6
(-)
NA
ETA, INF *, ETA, ADA
8
Pustulosa
No
Exacerbation
No
7
+
NA
ETA *
1
Vulgaris
No
Exacerbation
No
8
+
NA
ETA *
2
Vulgaris
No
Yes
No
9
+
NA
ADA *, INF
11
Vulgaris
No
Yes
No


*TNF-  antagonist with onset or exacerbation of psoriasis


ADA=adalimumab, ETA=etanercept, INF=infliximab; RF=rheumatoid factor


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Kary and colleagues note that a hypothetical explanation for the appearance or deterioration of psoriasis might be the overall enhanced susceptibility to bacterial infections caused by TNF inhibition, but, they point out, none of the patients had a preceding bacterial infection.

The researchers contend that RA patients rarely present with psoriasis of the skin. They point to the unpublished German national data bank for rheumatological diseases, which shows that only 26 out of more than 11¿400 patients with definite RA simultaneously had psoriasis.

The investigators conclude, "A study of such patients with new onset or aggravation of psoriasis during TNF-   blockade will be continued for further analysis of an underlying common pattern."


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Source

  1. Kary S, Worm M, Audring H, et al. New onset or exacerbation of psoriatic skin lesions in patients with definite rheumatoid arthritis receiving tumour necrosis factor alpha antagonists. Ann Rheum Dis 2006; 65:405-407. Abstract.


 

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