PSORIASIS PARADOXAL WITH INFLIXIMAB USE: A CASE REPORT

A 46-year-old female patient, diagnosed with Crohn's disease in the ileocolonic form in 2011. She used mesalazine and adalimumab for approximately two years and introduced infliximab eleven months after discontinuing the other medications, with a dosage of 4 vials every 2 months. The patient reports that one month after starting the medication, pruritic lesions began to appear on the fingers of both hands, with progressive worsening over 4 months, revealing erythematous-desquamative lesions on the palmoplantar region bilaterally, accompanied by pruritus. She also reports the appearance of blisters that soon collapsed, releasing clear fluid, with worsening after periods of stress. She denies lesions at other sites and reports no burning or pain. Her personal medical history includes Crohn's disease, depression, and hypertension. She continuously uses clonazepam 2mg, sertraline 100mg, losartan 100mg/day, hydrochlorothiazide 25mg once a day, and infliximab 4 vials every 2 months. Upon physical examination, erythematous-desquamative lesions and excoriations were noted on the palmoplantar region bilaterally. The case was discussed with the dermatology team, who advised that it was paradoxical psoriasis due to infliximab use. They recommended starting halobetasol 0.50mg cream twice a day and urea cream once a day for hydration. The appearance of the lesions improved 7 days after starting treatment. One of the reported side effects of immunobiologics is paradoxical psoriasis, in patients with or without a previous psoriatic disease. It is characterized by an acute reaction when occurring in less than 24 hours, and a delayed reaction between 24 hours and 14 days. It predominates in female patients and can occur in up to 5% of patients using anti-TNF. The most common clinical form is palmoplantar. The etiology is not well-defined but is related to the control between TNF-alpha levels and interferon with inflammatory cytokines. Treatment depends on the extent of the condition; in this patient, topical treatment was chosen while on immunobiologic therapy. However, it may be necessary to switch to another class of immunobiologics if the phenomenon persists or worsens. The treatment of paradoxical psoriasis remains a challenge, as most patients still require anti-TNF for the management of their underlying condition. Early identification of side effects and proper case management can allow the continuation of the initial immunobiologic treatment combined with topical treatment for psoriasis without affecting the patient's quality of life, always aiming for effective treatment and benefits.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
25 April 2025