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