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Rash induced by anti-tumor necrosis factor agents in an adolescent with Crohn's disease


Background. A 17-year-old white male with Crohn's disease who was receiving maintenance infusions of the anti-tumor necrosis factor (TNF) agent, infliximab, presented with a new-onset psoriasiform skin rash. The rash was not responsive to topical or oral corticosteroids and worsened after infliximab infusions and after subsequent administration of a second anti-TNF drug, adalimumab.

Investigations. Full medical history and physical examination, including assessment of the morphology of rash and the temporal correlation with administration of anti-TNF agents.

Diagnosis. Anti-TNF-agent induced psoriasiform skin rash.

Management. Discontinuation of anti-TNF therapy. The patient opted to have his gastrointestinal symptoms treated with oral mesalazine and metronidazole.

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Figure 1: Diffuse, erythematous, annular patches with areas of confluence can be seen extending across the trunk in this 17-year-old adolescent, following treatment with infliximab.
Figure 2


  1. Rutgeerts, P., Vermeire, S. & Van Assche, G. Biological therapies for inflammatory bowel diseases. Gastroenterology 136, 1182–1197 (2009).

    Article  CAS  Google Scholar 

  2. Rutgeerts, P. et al. Infliximab for induction and maintenance therapy for ulcerative colitis. N. Engl. J. Med. 354, 2462–2476 (2006).

    Google Scholar 

  3. Hanauer, S. B. et al. Maintenance infliximab for Crohn's disease: the ACCENT I randomized trial. Lancet 359, 1541–1549 (2002).

    Article  CAS  Google Scholar 

  4. Hyams, J. et al. Induction and maintenance Infliximab therapy for the treatment of moderate-to-severe Crohn's disease in children. Gastroenterology 132, 863–873 (2007).

    Article  CAS  Google Scholar 

  5. Eidelwein, A. P., Cuffari, C., Abadom, V. & Oliva-Hemker, M. Infliximab effiicacy in pediatric ulcerative colitis. Inflamm. Bowel Dis. 11, 213–218 (2005).

    Article  Google Scholar 

  6. Rosh, J. R. et al. Retrospective evaluation of the safety and effect of adalimumab therapy (RESEAT) in pediatric Crohn's disease. Am. J. Gastroenterol. 104, 3042–3049 (2009).

    Article  CAS  Google Scholar 

  7. Tracey, D., Klareskog, L., Sasso, E. H., Salfeld, J. G. & Tak, P. P. Tumor necrosis factor antagonist mechanisms of action: a comprehensive review. Pharmacol. Ther. 17, 244–279 (2008).

    Article  Google Scholar 

  8. Delle Sedie, A., Bazzichi, L., Bombardieri, S. & Riente, L. Psoriasis, erythema nodosum, and nummular eczema onset in an ankylosing spondylitis patient treated with infliximab. Scand. J. Rheumatol. 36, 403–404 (2007).

    Article  CAS  Google Scholar 

  9. Esmailzadeh, A. et al. Predictive factors of eczema-like eruptions among patients without cutaneous psoriasis receiving infliximab: a cohort study of 92 patients. Dermatology 219, 163–167 (2009).

    Article  Google Scholar 

  10. Asarch, A. et al. Lichen-planus-like eruptions: an emerging side effect of tumor necrosis factor-alpha antagonists. J. Am. Acad. Dermatol. 61, 104–111 (2009).

    Article  Google Scholar 

  11. Wollina, U. et al. Tumor necrosis factor-alpha inhibitor-induced psoriasis or psoriasiform exanthemata: first 120 cases from the literature including a series of six new patients. Am. J. Clin. Dermatol. 9, 1–14 (2008).

    Article  Google Scholar 

  12. Aslanidis, S., Pyrpasopoulou, A., Douma, S. & Triantafyllou, A. Tumor necrosis factor-α antagonist-induced psoriasis: yet another paradox in medicine. Clin. Rheumatol. 27, 377–380 (2008).

    Article  Google Scholar 

  13. Cohen, J. D. et al. Psoriasis induced by tumor necrosis factor-α antagonist therapy: a case series. J. Rheumatol. 34, 380–385 (2007).

    CAS  PubMed  Google Scholar 

  14. Verea, M. M., Del Pozo, J., Yebra-Pimentel, M. T., Porta, A. & Foseca, E. Psoriasiform eruption induced by infliximab. Ann. Pharmacother. 38, 54–57 (2004).

    Article  Google Scholar 

  15. Sfikakis, P. P., Iliopoulos, A., Elezoglou, A., Kittas, C. & Stratigos, A. Psoriasis induced by anti-tumor necrosis factor therapy. Arthritis Rheum. 52, 2513–2518 (2005).

    Article  CAS  Google Scholar 

  16. Goiriz, R., Daudén, E., Pérez-Gala, S., Guhl, G. & García-Díez, A. Flare and change of psoriasis morphology during the course of treatment with tumour necrosis factor blockers. Clin. Exp. Dermatol. 32, 167–169 (2007).

    Google Scholar 

  17. Harrrison, M. J. et al. Rates of new-onset psoriasis in patients with rheumatoid arthritis receiving anti-tumor necrosis factor α therapy: results from the British Society for Rheumatology Biologics Register. Ann. Rheum. Dis. 68, 209–215 (2009).

    Article  Google Scholar 

  18. Chaudhari, U. et al. Efficacy and safety of infliximab monotherapy for plaque-type psoriasis: a randomized trial. Lancet 357, 1842–1847 (2001).

    Article  CAS  Google Scholar 

  19. FDA alert. Information for healthcare professionals: tumor necrosis factor (TNF) blockers (marketed as Remicade, Enbrel, Humira, Cimzia, and Simponi) [online], (2009).

  20. Fiorino, G., Allez, M., Malesci, A. & Danese, S. Review article: anti TNF-α induced psoriasis in patients with inflammatory bowel disease. Aliment. Pharmacol. Ther. 29, 921–927 (2009).

    Article  CAS  Google Scholar 

  21. Nestle, F. O., Kaplan, D. H. & Barker, J. Psoriasis. N. Engl. J Med. 361, 496–509 (2009).

    Article  CAS  Google Scholar 

  22. Ko, J. M., Gottlieb, A. B. & Kerbleski, J. F. Induction and exacerbation of psoriasis with TNF-blockade therapy: a review and analysis of 127 cases. J. Dermatol. Treat. 20, 100–108 (2009).

    Article  CAS  Google Scholar 

  23. Lee, F. I., Bellary, S. V. & Francis, C. Increased occurrence of psoriasis in patients with Crohn's disease and their relatives. Am. J. Gastroenterol. 85, 962–963 (1990).

    CAS  PubMed  Google Scholar 

  24. Collamer, A. N., Guerrero, K. T., Henning, J. S. & Battafarano, D. F. Psoriatic skin lesions induced by tumor necrosis factor antagonist therapy: a literature review and potential mechanisms of action. Arthritis Rheum. 59, 996–1001 (2008).

    Article  CAS  Google Scholar 

  25. Carter, J. D., Gerard, H. C. & Hudson, A. P. Psoriasiform lesions induced by tumor necrosis factor antagonists: a skin-deep medical conundrum. Ann. Rheum. Dis. 67, 1181–1183 (2008).

    Article  CAS  Google Scholar 

  26. Palucka, A. K. et al. Cross-regulation of TNF and IFNα in autoimmune diseases. Proc. Natl Acad. Sci. USA 102, 3372–3377 (2005).

    Article  CAS  Google Scholar 

  27. Cuchacovich, R., Espinoza, C. G., Virk, Z. & Espinoza, L. R. Biologic therapy (TNF-α antagonists)-induced psoriasis: a cytokine imbalance between TNF-α and IFNα? J. Clin. Rheumatol. 14, 353–356 (2008).

    Article  Google Scholar 

  28. Seneschal, J. et al. Cytokine imbalance with increased production of interferon-alpha in psoriasiform eruptions associated with antitumour necrosis factor-alpha treatments. Br. J. Dermatol. 161, 1081–1088 (2009).

    Article  CAS  Google Scholar 

  29. Michaelsson, G., Kajermo, U., Michaelsson, A. & Hagforsen, E. Infliximab can precipitate as well as worsen palmoplantar pustulosis: possible linkage to the expression of tumour necrosis factor-α in the normal palmar eccrine sweat duct? Br. J. Dermatol. 153, 1220–1221 (2005).

    Article  Google Scholar 

  30. Costa-Romero, M., Coto-Segura, P., Suarez-Saavedra, S., Ramos-Polo, E. & Santos-Juanes, J. Guttate psoriasis induced by Infliximab in a child with Crohn's disease. Inflamm. Bowel Dis. 14, 1462–1463 (2008).

    Article  Google Scholar 

  31. Peek, R., Scott-Jupp, R., Strike, H., Clinch, J. & Ramanan, A. V. Psoriasis after treatment of juvenile idiopathic arthritis with etanercept. Ann. Rheum. Dis. 65, 1259 (2006).

    Article  CAS  Google Scholar 

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Correspondence to Maria Oliva-Hemker.

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Competing interests

Bernard Cohen reports receiving support for a CME program from Centocor. Lindsay Wilson reports receiving research support from UCB. Maria Oliva-Hemker reports receiving research support from Centocor and Abbott Immunology. The other authors declare no competing interests.

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Conklin, L., Cohen, B., Wilson, L. et al. Rash induced by anti-tumor necrosis factor agents in an adolescent with Crohn's disease. Nat Rev Gastroenterol Hepatol 7, 174–177 (2010).

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