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P220. Induction of psoriasis with anti-TNF agents in patients with inflammatory bowel disease: A report of 19 cases

I. Guerra1, A. Algaba1, J. Pérez-Calle2, M. Chaparro3, I. Marín-Jimenez4, A. López-Sanromán5, R. García-Castellanos6, Y. González-Lama7, N. Manceñido8, P. Martínez9, E. Quintanilla10, C. Taxonera11, M. Villafruela12, A. Romero1, P. López-Serrano2, J.P. Gisbert3, F. Bermejo1

1Hospital de Fuenlabrada, Fuenlabrada, Spain; 2Hospital de Alcorcón, Alcorcón, Spain; 3Hospital La Princesa, Madrid, Spain; 4Hospital Gregorio Marañón, Madrid, Spain; 5Hospital Ramón y Cajal, Madrid, Spain; 6Fundación Jiménez Díaz, Madrid, Spain; 7Hospital Puerta de Hierro, Majadahonda, Spain; 8Hospital Infanta Sofía, San Sebastián de Los Reyes, Spain; 9Hospital Doce de Octubre, Madrid, Spain; 10Hospital Severo Ochoa, Leganés, Spain; 11Hospital Clínico San Carlos, Madrid, Spain; 12Hospital Príncipe de Asturias, Alcalá de Henares, Spain

Aim: Anti-tumor necrosis factor (TNF)-alpha agents are widely used for the treatment of both inflammatory bowel disease (IBD) and psoriasis. Psoriatic skin lesions induced by anti-TNF have been described in patients with IBD. We report a case series of psoriasis induced by anti-TNF agents in IBD patients.

Methods: We conducted a systematic analysis of the cases we observed among our IBD patient cohort in tertiary hospitals of Madrid with psoriasis induced by anti-TNF (infliximab or adalimumab).

Results: A total of 19 of 1283 patients with IBD treated with anti TNF-alpha agents developed drug-induced psoriasis (cumulative incidence 1.48%; 95% CI 0.95–2.30): 12 patients with infliximab and 7 with adalimumab. Indication of treatment: 16 Crohn's disease, 3 ulcerative colitis. Age 40±10 years, 14 females, 47% smokers. The onset of skin lesions was variable in time (after 13±9 doses), all during maintenance therapy, except 1 patient who developed psoriasis after the third induction dose of infliximab. Three patients had history of psoriasis before the treatment, and psoriasis reappeared with the anti-TNF therapy. The most frequent site of skin lesions was limbs (63%) followed by trunk (47%) and scalp (42%). Psoriasis phenotypes were plaque psoriasis (58%), scalp (16%), palmoplantar pustulosis (11%), pustular generalized psoriasis (5%), guttate (5%) and inverse (5%). Withdrawal of anti-TNF in 4 patients led to complete regression of lesions in 1 of them, with no further recurrence of psoriasis. The other 3 patients presented partial response, and anti-TNF was permanently discontinued in 2 of them. The other 15 patients were managed with topical steroids or a combination with other topical drugs, and 2 patients were treated with associated UVA therapy. Only 1 patient didn't respond to this strategy, and then the anti-TNF was withdrawn with complete response. Two patients were switched between anti-TNF agents (1 to infliximab and 1 to adalimumab) because of partial response. With the second anti-TNF both patients presented mild recurrence of psoriasis, with complete response to topical treatment.

Conclusion: Psoriasis sometimes develops during maintenance treatment and plaque psoriasis in extremities and trunk were the most frequent presentations in our series. Topical steroid treatment is effective in most patients. Anti-TNF withdrawal could be reserved for patients with severe psoriasis or patients without response to topical therapy.