CLINICAL REPORT
731
ActaDV ActaDV Advances in dermatology and venereology Acta Dermato-Venereologica
Pattern and Severity of Psoriasiform Eruptions in Patients with Inflammatory Bowel Diseases, Arthritis or Skin Inflammatory Disorders Treated with TNF-alpha Inhibitors
Anne-Sophie DARRIGADE 1, Brigitte MILPIED 1, Marie-Elise TRUCHETET 2, Thierry SCHAEVERBEKE 2, David LAHARIE 3, Frank ZERBIB 3, Marie BEYLOT-BARRY 1, Thomas JOUARY 4, Alain TAIEB 1, Khaled EZZEDINE 1 and Julien SENESCHAL 1
1
Department of Dermatology and Pediatric Dermatology, National Centre for Rare Skin Disorders, Saint-André Hospital, 2 Department of Rheumatology, Pellegrin Hospital, 3 Department of Gastroenterology, Haut-Lévêque Hospital, Bordeaux, and 4 Department of Dermatology, François Mitterand Hospital, Pau, France
Psoriasiform eruptions are a classical adverse skin reaction of tumour necrosis factor( TNF)-α inhibitors. The aim of this study was to identify the association between the severity or pattern of psoriasiform reactions and the underlying disease. A retrospective study was conducted between January 2012 and May 2015. Adult patients who developed psoriasiform eruptions whilst being treated with TNFα inhibitors were included. For each patient, 3 independent blinded dermatologists graded twice the severity of the lesions according to 6 clinical psoriasiform eruption types. Inter- and intra-individual kappa tests were performed to evaluate the robustness of the scoring system. The association between severity score levels or the pattern of reactions and the underlying disease was assessed. The severity scoring system showed good inter- and intra-observer reproducibility. Women patients treated with TNFα inhibitors for inflammatory bowel diseases showed a higher risk of developing severe reactions with scalp and skin-fold involvement.
Key words: TNF-α inhibitors; psoriasiform eruption; inflammatory bowel disease; arthritis; psoriasis; tumour necrosis factor.
Accepted Feb 20, 2017; Epub ahead of print Feb 20, 2017 Acta Derm Venereol 2017; 97: 731 – 734.
Corr: Julien Seneschal, Department of Dermatology and Pediatric Dermatology; National Centre for Rare Skin Disorders, Saint-André Hospital, 1 rue Jean Burguet, FR-33075 Bordeaux, Cedex, France. E-mail: julien. seneschal @ chu-bordeaux. fr
Treatment with tumour necrosis factor( TNF)-α inhibitors has profoundly changed the course of inflammatory diseases, such as inflammatory bowel diseases( IBD), inflammatory rheumatism( IR) and psoriasis( 1). While TNFα inhibitor therapies are generally well tolerated, their use has been associated with a wide range of adverse events, including cutaneous events. Psoriasiform eruptions are the most common inflammatory skin adverse events reported so far. Their prevalence ranges from 0.6 % to 5.3 % in patients treated with these therapies( 2 – 8). Psoriasiform eruptions have been observed with all the TNFα inhibitors( 7, 9, 10) and are characterized by various clinical presentations, including palmoplantar keratoderma or pustulosis, and skin-fold or scalp lesions, which lead to diagnostic difficulties. Severe manifestations, such as alopecia, generalized psoriasiform plaques or pustulosis, can lead to treatment discontinuation with a potential risk of flare-up of the underlying disease( 9 – 12). Therefore, we sought to identify a potential association between the severity or the pattern of the psoriasiform reactions under treatment with TNFα inhibitors and the underlying disease using a new validated severity scoring system.
PATIENTS AND METHODS Population and study sample
We conducted a retrospective single-centre study between January 2012 and May 2015 in the department of dermatology at the University Hospital in Bordeaux. All patients aged 18 years or over were referred to our clinic in the first 3 months after the onset of the psoriasiform eruption. Patients were referred from the gastroenterology, rheumatology, dermatology and internal medicine departments. Each patient completed a standardized questionnaire including demographic and clinical characteristics, underlying inflammatory conditions, type and dose of TNFα inhibitors initiated, concomitant therapies and delay between administration of TNFα inhibitors and the onset of psoriasiform eruptions. Written informed consent was obtained from all patients.
Clinical features of psoriasiform eruptions
Psoriasiform eruptions were defined as a cutaneous eruption occurring during treatment with TNFα inhibitors in a patient with no personal history of similar lesions. The absence or presence of each of the 6 following patterns was noted: palmoplantar keratoderma( PPK), palmoplantar pustulosis( PPP), psoriasiform plaques, skin-fold involvement, scalp involvement and generalized pustulosis.
Scoring system and statistical analysis
Three experienced dermatologists( A, B, C) independently rated the photographs of the psoriasiform lesions twice with a 15-day interval. For each patient, the 6 patterns were assessed with a 3-grade severity score( 0 for no lesion, 1 for mild involvement and 2 for severe involvement)( Fig. 1). Intra- and inter-observer reproducibility of ratings between each pair of dermatologists was estimated using kappa statistics( A and B, A and C, B and C)( 13). A kappa statistic with equal-spacing weights was used to estimate the degree of agreement between the pairs of dermatologists. The 5-level nomenclature proposed by Landis & Koch( 14) was used to interpret the level of agreement.
This is an open access article under the CC BY-NC license. www. medicaljournals. se / acta Journal Compilation © 2017 Acta Dermato-Venereologica. doi: 10.2340 / 00015555-2636 Acta Derm Venereol 2017; 97: 731 – 734