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Liu K, Sun J. Behcet's-like disease induced by secukinumab in a patient with psoriasis: a case report and literature review. J DERMATOL TREAT 2024; 35:2347440. [PMID: 38857894 DOI: 10.1080/09546634.2024.2347440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/14/2024] [Indexed: 06/12/2024]
Abstract
Purpose: The incidence of cutaneous paradoxical reactions associated with IL-17 inhibitors has gained attention in recent literature. Our report aims to investigate the characteristics of one rare paradoxical reaction, presenting as Behcet's disease. Methods: We reported one case of Behcet's-like disease induced by secukinumab in a patient with psoriasis. This patient, a young woman with a long history of psoriasis, showed significant improvement in her psoriatic condition after receiving four doses of secukinumab. Unexpectedly, she developed symptoms such as high fever, painful oral and genital ulcers, facial maculopapules, and erythema nodosum-like lesions on her lower limbs. Despite neutrophilia, there was no evidence of infection found in her laboratory tests. Histological analysis of a skin biopsy highlighted subcutaneous panniculitis and a mixed inflammatory cell infiltrate in the dermis. The patient was consequently diagnosed with secukinumab-induced Behcet's-like disease. Additionally, we have reviewed nine other documented cases of Behcet's-like disease triggered by IL-17 inhibitors. Results: This group showed no significant gender preference, suffering from conditions such as psoriasis, ankylosing spondylitis, and hidradenitis suppurativa. Oral and genital ulcers were prevalent among the paradoxical reactions noted. Marked improvement was observed in all patients upon discontinuation of the IL-17 inhibitors. Conclusions: Our report serves to alert physicians to this uncommon but significant paradoxical effect that may arise with anti-IL-17 treatment.
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Affiliation(s)
- Kecen Liu
- Department of Dermatology and Venerology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- NMPA Key Laboratory for Quality Control and Evaluation of Cosmetics, Beijing, China
| | - Jingru Sun
- Department of Dermatology and Venerology, Peking University First Hospital, Beijing, China
- Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
- National Clinical Research Center for Skin and Immune Diseases, Beijing, China
- NMPA Key Laboratory for Quality Control and Evaluation of Cosmetics, Beijing, China
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2
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Maronese CA, Valenti M, Moltrasio C, Romagnuolo M, Ferrucci SM, Gilliet M, Costanzo A, Marzano AV. Paradoxical Psoriasis: An Updated Review of Clinical Features, Pathogenesis, and Treatment Options. J Invest Dermatol 2024:S0022-202X(24)01731-7. [PMID: 38958610 DOI: 10.1016/j.jid.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/03/2024] [Accepted: 05/11/2024] [Indexed: 07/04/2024]
Abstract
The definition of paradoxical psoriasis (PP) encompasses 2 main scenarios, namely, (i) new-onset psoriasis in patients treated for a different disease and (ii) worsening as well as phenotypical change of pre-existing psoriasis. Originally restricted to the appearance of an untoward psoriasiform reaction under TNF inhibitors, the term has gained new meaning, with the progressive observation of psoriasis-like eruptions also with other medications. Although the conceptual framework of PP has expanded, a molecular and clinicotherapeutic classification is still lacking. In addition, a certain degree of confusion surrounds the correct terminology to indicate these eruptions. In this paper, evidence on the epidemiology, clinical features, pathogenesis, and treatment of PP is reviewed, providing a perspective on possible pathogenesis-driven therapeutic approaches.
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Affiliation(s)
- Carlo Alberto Maronese
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Mario Valenti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Chiara Moltrasio
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maurizio Romagnuolo
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Mariel Ferrucci
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michel Gilliet
- Department of Dermatology, CHUV University Hospital and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Antonio Costanzo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.
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3
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Wride AM, Chen GF, Spaulding SL, Tkachenko E, Cohen JM. Biologics for Psoriasis. Dermatol Clin 2024; 42:339-355. [PMID: 38796266 DOI: 10.1016/j.det.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Biologic therapies targeting tumor necrosis factor alpha (TNF-α) (infliximab, adalimumab, certolizumab, etanercept), the p40 subunit shared by IL-12 and IL-23 (ustekinumab), the p19 subunit of IL-23 (guselkumab, tildrakizumab, risankizumab), IL-17A (secukinumab, ixekizumab), IL-17-RA (brodalumab) and both IL-17A and IL-17F (bimekizumab) have revolutionized the treatment of psoriasis. In both the short and long term, risankizumab had highest Psoriasis Area and Severity Index 90 scores compared to other oral and injectable biologics. IL-23 inhibitors had lowest rates of short-term and long-term adverse events and most favorable long-term risk-benefit profile compared to IL-17, IL-12/23, and TNF-α inhibitors.
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Affiliation(s)
- Anthony Mitchel Wride
- Department of Dermatology, Yale School of Medicine, Yale University, 15 York Street, New Haven, CT 06510, USA
| | - Gloria F Chen
- Department of Dermatology, Yale School of Medicine, Yale University, 15 York Street, New Haven, CT 06510, USA
| | - Sarah L Spaulding
- Department of Dermatology, Yale School of Medicine, Yale University, 15 York Street, New Haven, CT 06510, USA
| | - Elizabeth Tkachenko
- Department of Dermatology, Yale School of Medicine, Yale University, 15 York Street, New Haven, CT 06510, USA
| | - Jeffrey M Cohen
- Department of Dermatology, Yale School of Medicine, Yale University, 15 York Street, New Haven, CT 06510, USA.
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4
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Hartmane I. Study of Genetic Mutations and Their Association With the Development of Atopic Dermatitis and Other Skin Diseases. PLASTIC AND AESTHETIC NURSING 2024; 44:200-209. [PMID: 39028474 DOI: 10.1097/psn.0000000000000564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
The purpose of this study was to identify the heterogeneity of atopic dermatitis and to identify key genetic factors. This can lead to new approaches and personalized treatment strategies. I conducted a literature review of three scientific publication platforms (i.e., PubMed, Cochrane Library, Scopus) for records published between July 2011 and July 2023 using key words related to the genetics of atopic dermatitis. The high heritability and genetic pleiotropia of atopic dermatitis emphasize the importance of its genetic predisposition and interaction with concomitant diseases. The study also shows the role of various genes associated with immunity and inflammatory reactions, as well as the high heritability of atopic dermatitis, particularly among twins. Genetic mutations, specifically polymorphisms of genes encoding immune factors and inflammatory responses, determine an individual's predisposition to atopic dermatitis. Research findings also point to genetic aspects associated with other skin conditions such as psoriasis and vitiligo, confirming the existence of common genetic mechanisms between these diseases. Specifically, polymorphisms of the filaggrin gene have been found to be key genetic determinants of atopic dermatitis. I analyzed the genetic basis of atopic dermatitis, emphasizing the importance of genetic determinants and their interaction with the immune system and extracellular matrix. This study contributes to the understanding of the mechanisms of atopic dermatitis and opens new perspectives for individualized treatments.
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Affiliation(s)
- Ilona Hartmane
- Ilona Hartmane, MD, is a Dermatologist at the Department of Dermatology and Venereology, Rīga Stradinš University, Rīga, Latvia
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5
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Abdelghaffar M, Kottilil S, Murphy MJ, Cohen JM, Damsky W. Paradoxical Psoriasis. Dermatol Clin 2024; 42:471-480. [PMID: 38796276 DOI: 10.1016/j.det.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Cytokine blocking therapies have revolutionized the management of psoriasis and atopic dermatitis but can lead to the development of paradoxic psoriasis (PP). Patients treated with biologics should be closely monitored for the development of PP and other paradoxical eruptions (including inflammatory joint disease, inflammatory bowel disease, eczematous eruptions, lupus like eruptions, sarcoidal eruptions, and others) and occasionally the development of cutaneous T-cell lymphoma. Further understanding the immunologic mechanism of these processes will ultimately drive our understanding of and ability to predict and manage PPs.
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Affiliation(s)
- Mariam Abdelghaffar
- School of Medicine, Royal College of Surgeons in Ireland, Building No. 2441, Road 2835, Busaiteen 228, Bahrain
| | | | - Michael J Murphy
- Department of Dermatology, Yale School of Medicine, 333 Cedar Street, PO Box 208059, New Haven, CT 06510, USA
| | - Jeffrey M Cohen
- Department of Dermatology, Yale School of Medicine, 333 Cedar Street, PO Box 208059, New Haven, CT 06510, USA
| | - William Damsky
- Department of Dermatology, Yale School of Medicine, 333 Cedar Street, PO Box 208059, New Haven, CT 06510, USA.
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6
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Sanz Segura P, Gomollón F, Casas D, Iborra M, Vela M, Fernández-Clotet A, Muñoz R, García de la Filia I, García Prada M, Ferrer Rosique JÁ, García MJ, de Francisco R, Arias L, Barrio J, Guerra I, Ponferrada Á, Gisbert JP, Carrillo-Palau M, Calvet X, Márquez-Mosquera L, Gros B, Cañete F, Monfort D, Madrigal Domínguez RE, Roncero Ó, Laredo V, Montoro M, Muñoz C, López-Cauce B, Lorente R, Fuentes Coronel A, Vega P, Martín D, Peña E, Varela P, Olivares S, Pajares R, Lucendo AJ, Sesé E, Botella Mateu B, Nos P, Domènech E, García-López S. Psoriasis induced by antiTNF therapy in inflammatory bowel disease: Therapeutic management and evolution of both diseases in a nationwide cohort study. Dig Liver Dis 2024:S1590-8658(24)00779-5. [PMID: 38876834 DOI: 10.1016/j.dld.2024.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 05/19/2024] [Accepted: 05/20/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND some patients with inflammatory bowel disease (IBD) treated with antiTNF develop drug-induced psoriasis (antiTNF-IP). Several therapeutic strategies are possible. AIMS to assess the management of antiTNF-IP in IBD, and its impact in both diseases. METHODS patients with antiTNF-IP from ENEIDA registry were included. Therapeutic strategy was classified as continuing the same antiTNF, stopping antiTNF, switch to another antiTNF or swap to a non-antiTNF biologic. IP severity and IBD activity were assessed at baseline and 16, 32 and 54 weeks. RESULTS 234 patients were included. At baseline, antiTNF-IP was moderate-severe in 60 % of them, and IBD was in remission in 80 %. Therapeutic strategy was associated to antiTNF-IP severity (p < 0.001). AntiTNF-IP improved at week 54 with all strategies, but continuing with the same antiTNF showed the worst results (p = 0.042). Among patients with IBD in remission, relapse was higher in those who stopped antiTNF (p = 0.025). In multivariate analysis, stopping antiTNF, trunk and palms and soles location were associated with antiTNF-IP remission; female sex and previous surgery in Crohn´s disease with IBD relapse. CONCLUSION skin lesions severity and IBD activity seem to determine antiTNF-IP management. Continuing antiTNF in mild antiTNF-IP, and swap to ustekinumab or switch to another antiTNF in moderate-severe cases, are suitable strategies.
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Affiliation(s)
| | - Fernando Gomollón
- Gastroenterology Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain; Instituto de Investigación Sanitaria (ISS) Aragón, Zaragoza, Spain
| | - Diego Casas
- Instituto de Investigación Sanitaria (ISS) Aragón, Zaragoza, Spain; Gastroenterology Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Marisa Iborra
- Gastroenterology Department, Hospital Universitario La Fe, Valencia, Spain
| | - Milagros Vela
- Gastroenterology Department, Hospital Universitario Ntra. Sra. de Candelaria, Santa Cruz de Tenerife, Spain
| | - Agnès Fernández-Clotet
- Gastroenterology Department, Hospital Clinic de Barcelona. Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd). Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Roser Muñoz
- Gastroenterology Department, Hospital General Universitario Dr. Balmis, Alicante, Spain
| | | | - María García Prada
- Gastroenterology Department, Complejo Asistencial Universitario de León, Spain
| | | | - María José García
- Gastroenterology and Hepatology Department, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Ruth de Francisco
- Gastroenterology Department, Hospital Universitario Central de Asturias, and Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Lara Arias
- Gastroenterology Department, Hospital Universitario de Burgos, Burgos, Spain
| | - Jesús Barrio
- Gastroenterology Department, Hospital Universitario Río Hortega. Gerencia Regional de Salud de Castilla y León (SACYL). Valladolid, Spain
| | - Iván Guerra
- Gastroenterology Department, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Ángel Ponferrada
- Gastroenterology Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Javier P Gisbert
- Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Marta Carrillo-Palau
- Gastroenterology Department, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - Xavier Calvet
- Servei d'Aparell Digestiu. Parc Taulí, Hospital Universitari. Institutd'Investigació i Innovació Parc Taulí(I3PT-CERCA). Universitat Autònoma de Barcelona. Sabadell, Spain. Centro de Investigación Biomédica En Red de enfermedades hepáticas y digestivas (CIBERehd). Instituto de Salud Carlos III. Madrid, Spain
| | - Lucía Márquez-Mosquera
- Servei de Digestiu, Hospital del Mar, Barcelona, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Beatriz Gros
- Gastroenterology Department, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Fiorella Cañete
- Gastroenterology Department, Hospital Universitari Germans Trials i Pujol and CIBERehd, Badalona, Barcelona, Spain
| | - David Monfort
- Gastroenterology Department, Consorci Sanitari de Terrassa, Spain
| | | | - Óscar Roncero
- Gastroenterology Department, Hospital General La Mancha Centro, Ciudad Real, Spain
| | - Viviana Laredo
- Gastroenterology Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Miguel Montoro
- Gastroenterology Department, Hospital San Jorge, Huesca, Spain
| | - Carmen Muñoz
- Gastroenterology Department, Hospital de Basurto, Bilbao, Spain
| | - Beatriz López-Cauce
- Gastroenterology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rufo Lorente
- Gastroenterology Department, Hospital General de Ciudad Real, Ciudad Real, Spain
| | - Ana Fuentes Coronel
- Gastroenterology Department, Hospital Virgen de La Concha, Complejo Asistencial de Zamora, Zamora, Spain
| | - Pablo Vega
- Gastroenterology Department, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Dolores Martín
- Gastroenterology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Elena Peña
- Gastroenterology Department, Hospital Royo Villanova, Zaragoza, Spain
| | - Pilar Varela
- Gastroenterology Department, Hospital Universitario de Cabueñes, Gijón, Spain
| | | | - Ramón Pajares
- Gastroenterology Department, Hospital Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - Alfredo J Lucendo
- Gastroenterology Department, Hospital General de Tomelloso, IIS-IP, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM) and CIBEREHD Ciudad Real, Spain
| | - Eva Sesé
- Gastroenterology Department, Hospital Universitario Arnau de Vilanova de Lleida, Spain
| | - Belén Botella Mateu
- Gastroenterology Department, Hospital Universitario Infanta Cristina, Madrid, Spain
| | - Pilar Nos
- Gastroenterology Department, Hospital Universitario La Fe, Valencia, Spain
| | - Eugeni Domènech
- Gastroenterology Department, Hospital Universitari Germans Trials i Pujol and CIBERehd, Badalona, Barcelona, Spain
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Deng S, Wang H, Chen Q, Chen X, Song X, Chen S, Kong M, Song Z. Long-term, observational, real-world study of dupilumab for the treatment of moderate-to-severe atopic dermatitis: a 52-week single-center retrospective analysis in China. Arch Dermatol Res 2024; 316:304. [PMID: 38819652 DOI: 10.1007/s00403-024-03029-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 04/09/2024] [Accepted: 04/26/2024] [Indexed: 06/01/2024]
Abstract
For dupilumab, real-world long-term follow-up data remain scarce, and studies on optimized treatment modes as well as drug survival rate and its predictors are lacking. To explore the effectiveness of different treatment modes of dupilumab and to understand the drug survival rates of dupilumab in China and its predictive factors. This retrospective study included patients with moderate-to-severe AD who received dupilumab treatment. Their clinical data were collected and analyzed. Compared with baseline, the SCORing Atopic Dermatitis (SCORAD), Eczema Area and Severity Index (EASI), numerical rating scale (NRS), and Atopic Dermatitis Control Tool (ADCT) scores significantly decreased at 12, 24, and 52 weeks (p < 0.0001), and the continuous medication group had more significant improvements in SCORAD, EASI, NRS, and ADCT scores at 52 weeks than the noncontinuous medication group (p < 0.05). The 6-month and 1-year drug survival rates of dupilumab were 59.7% and 51.9%, respectively. The most common reason for treatment discontinuation was the satisfactory control of AD. Patients with adult-onset AD (adjusted odds ratio [OR]: 0.15, 95% confidence interval [CI]: 0.03-0.73) , not complicated by other systemic diseases (adjusted OR: 0.17, 95% CI: 0.04-0.84) and eosinophilia at baseline (adjusted OR: 3.71, 95% CI: 1.12-12.26) had a higher probability of drug discontinuation. In real-world practice in China, dupilumab has exhibited good long-term effectiveness and safety for the treatment of moderate-to-severe AD, and continuous administration can benefit patients in the long term.
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Affiliation(s)
- Sisi Deng
- Department of Dermatology, Southwest Hospital, Army Medical University, No.30, Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Huan Wang
- Department of Dermatology, Southwest Hospital, Army Medical University, No.30, Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Qiquan Chen
- Department of Dermatology, Southwest Hospital, Army Medical University, No.30, Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Xueqin Chen
- Department of Dermatology, Southwest Hospital, Army Medical University, No.30, Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Xiao Song
- Department of Dermatology, Southwest Hospital, Army Medical University, No.30, Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Shuguang Chen
- Department of Dermatology, Southwest Hospital, Army Medical University, No.30, Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Minmin Kong
- Department of Dermatology, Southwest Hospital, Army Medical University, No.30, Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Zhiqiang Song
- Department of Dermatology, Southwest Hospital, Army Medical University, No.30, Gaotanyan Street, Shapingba District, Chongqing, 400038, China.
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8
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Henckens NFT, Thomas SE, van den Reek JMPA, de Jong EMGJ. Multi-treatment resistance to biological treatment in patients with psoriasis: Definitions and implications. J Eur Acad Dermatol Venereol 2024. [PMID: 38818854 DOI: 10.1111/jdv.20133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 05/06/2024] [Indexed: 06/01/2024]
Affiliation(s)
- N F T Henckens
- Department of Dermatology, Radboud University Medical Centre (Radboudumc), Nijmegen, The Netherlands
| | - S E Thomas
- Department of Dermatology, Radboud University Medical Centre (Radboudumc), Nijmegen, The Netherlands
| | - J M P A van den Reek
- Department of Dermatology, Radboud University Medical Centre (Radboudumc), Nijmegen, The Netherlands
| | - E M G J de Jong
- Department of Dermatology, Radboud University Medical Centre (Radboudumc), Nijmegen, The Netherlands
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9
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Potestio L, Lauletta G, Tommasino N, Portarapillo A, Salsano A, Battista T, Martora F, Megna M. Risk Factors for Psoriasis Flares: A Narrative Review. PSORIASIS (AUCKLAND, N.Z.) 2024; 14:39-50. [PMID: 38831846 PMCID: PMC11146339 DOI: 10.2147/ptt.s323281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 05/25/2024] [Indexed: 06/05/2024]
Abstract
Psoriasis is a chronic inflammatory cutaneous disease with multifactorial pathogenesis involving both genetic and environmental factors as well as the innate and acquired immune response. Several triggering factors may exacerbate or worsen the disease. In this context, we performed a review manuscript with the aim of investigating current literature on psoriasis risk factors, also showing possible mechanisms by which they act on psoriasis. Globally, risk factors can be divided in classic risk factors (eg, mechanical stress, infections and dysbiosis of the skin, common drugs, environment and pollution, lifestyle, psychological stress, hormonal and metabolic alterations) which have long been known to be responsible for worsening and/or reoccurrence of psoriatic manifestations, and emerging risk factors (eg, biological drugs, immunotherapy for oncologic disease, Covid-19, and vaccines) defined as those newly identified risk factors. Accurate patient information and monitoring of risk factors as well as planned follow-ups may help to prevent and treat the worsening of psoriasis and consequently improve the quality of life of psoriatic patients.
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Affiliation(s)
- Luca Potestio
- Section of Dermatology - Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Giuseppe Lauletta
- Section of Dermatology - Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Nello Tommasino
- Section of Dermatology - Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Antonio Portarapillo
- Section of Dermatology - Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Antonia Salsano
- Section of Dermatology - Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Teresa Battista
- Section of Dermatology - Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Fabrizio Martora
- Section of Dermatology - Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Matteo Megna
- Section of Dermatology - Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
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10
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Irie K, Takada M, Yamamoto T. Guselkumab-induced paradoxical exacerbation of extra-palmoplantar lesions in a patient with palmoplantar pustulosis. J Dermatol 2024. [PMID: 38660964 DOI: 10.1111/1346-8138.17248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/06/2024] [Accepted: 04/09/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Kinuko Irie
- Department of Dermatology, Fukushima Medical University, Fukushima, Japan
| | - Maki Takada
- Department of Dermatology, Fukushima Medical University, Fukushima, Japan
| | - Toshiyuki Yamamoto
- Department of Dermatology, Fukushima Medical University, Fukushima, Japan
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11
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Falcinelli F, Lazzeri L, Tognetti L, Bardelli M, Rubegni P, Russo F. Development of a sebo-psoriasis-like dermatosis: a newly paradoxical reaction due to ixekizumab described with line-field confocal optical coherence tomography. Ital J Dermatol Venerol 2024; 159:197-198. [PMID: 38127319 DOI: 10.23736/s2784-8671.23.07661-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Affiliation(s)
- Francesca Falcinelli
- Unit of Medical, Surgical and Neurological Science, Dermatology Section, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy -
| | - Laura Lazzeri
- Unit of Medical, Surgical and Neurological Science, Dermatology Section, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
| | - Linda Tognetti
- Unit of Medical, Surgical and Neurological Science, Dermatology Section, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
| | - Marco Bardelli
- Unit of Rheumatology, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Pietro Rubegni
- Unit of Medical, Surgical and Neurological Science, Dermatology Section, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
| | - Filomena Russo
- Unit of Medical, Surgical and Neurological Science, Dermatology Section, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
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12
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Li J, Wang S, Li XD, Han Y. Combination of secukinumab and acitretin for generalized pustular psoriasis: A case report and review of literature. J Int Med Res 2024; 52:3000605241247702. [PMID: 38661102 PMCID: PMC11047231 DOI: 10.1177/03000605241247702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/31/2024] [Indexed: 04/26/2024] Open
Abstract
Generalized pustular psoriasis (GPP) is characterized by painful and occasionally disfiguring cutaneous manifestations with sepsis-like systemic symptoms, and is a rare severe variant of psoriasis. Currently, there is no standard treatment for GPP. Here, we report a case of a female patient with ankylosing spondylitis (AS) and mild scalp psoriasis, who developed GPP and alopecia following three courses of adalimumab therapy. The patient's condition gradually improved following cessation of adalimumab and treatment with secukinumab and acitretin. After eight weeks of treatment, the patient achieved almost complete clearance of her psoriasis, her alopecia improved, and her AS was relieved. Therefore, we believe that a combination of secukinumab with acitretin may be a rational approach for the treatment of severe GPP.
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Affiliation(s)
- Ji Li
- Department of Dermatology, Central Hospital Affiliated To ShenYang Medical College, 5 Nanqi West Road, 110024, Shenyang, Liaoning, China
| | - Shiyu Wang
- Department of Dermatology, Central Hospital Affiliated To ShenYang Medical College, 5 Nanqi West Road, 110024, Shenyang, Liaoning, China
| | - Xiao-Dong Li
- Department of Dermatology, Central Hospital Affiliated To ShenYang Medical College, 5 Nanqi West Road, 110024, Shenyang, Liaoning, China
| | - Yang Han
- Department of Dermatology, Central Hospital Affiliated To ShenYang Medical College, 5 Nanqi West Road, 110024, Shenyang, Liaoning, China
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13
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Maronese CA, Costanzo A, Gilliet M, Marzano AV. Paradoxical Psoriasis: From Its Many Faces to Possible Shared Therapeutic Targets. J Invest Dermatol 2024:S0022-202X(24)00195-7. [PMID: 38513820 DOI: 10.1016/j.jid.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 02/13/2024] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Carlo Alberto Maronese
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Antonio Costanzo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy; Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Michel Gilliet
- Department of Dermatology, CHUV University Hospital and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.
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14
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Kim RW, Lam M, Abuabara K, Simpson EL, Drucker AM. Targeted Systemic Therapies for Adults with Atopic Dermatitis: Selecting from Biologics and JAK Inhibitors. Am J Clin Dermatol 2024; 25:179-193. [PMID: 38216802 DOI: 10.1007/s40257-023-00837-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/14/2024]
Abstract
Therapeutic options for people with moderate or severe atopic dermatitis refractory to topical therapy have rapidly expanded in recent years. These new targeted immunomodulatory agents-biologics and Janus kinase (JAK) inhibitors-have each demonstrated high levels of efficacy and acceptable safety in mostly placebo-controlled clinical trials for atopic dermatitis, but there is no universally applicable algorithm to help choose between them for a given patient. Hence, patients and physicians should utilize shared decision making, discussing efficacy, safety, mode of delivery, monitoring, costs, speed of onset, and other factors to reach individualized treatment decisions. In this review, we try to aid shared decision making by summarizing the efficacy, safety, and monitoring of biologics and oral JAK inhibitors for adults with atopic dermatitis. Network meta-analyses suggest that higher doses of abrocitinib and upadacitinib are more effective than biologics. They also show that, among biologics, dupilumab is likely more effective than tralokinumab and lebrikizumab. Biologics are generally considered safer than JAK inhibitors, although concerns about JAK inhibitors are mainly extrapolated from older generation JAK inhibitors used in higher-risk populations. We also outline evidence and considerations for choosing and using systemic immunomodulatory treatments for special populations including pregnant individuals, those with human immunodeficiency virus (HIV), hepatitis B and C, end stage kidney disease, and older adults.
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Affiliation(s)
- Richard W Kim
- University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Megan Lam
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Katrina Abuabara
- Department of Dermatology, University of California San Francisco, San Francisco, CA, USA
- Division of Epidemiology and Biostatistics, University of California, Berkeley School of Public Health, Berkeley, CA, USA
| | - Eric L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Aaron M Drucker
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Medicine and Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.
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15
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Sun R, Bustamante M, Gurusamy VK, Lebwohl M, Gottlieb AB, Mease PJ, Deodhar A, Bao W, Mendelson M, Porter B, Chand D, Dong V. Safety of Secukinumab from 1 Million Patient-Years of Exposure: Experience from Post-Marketing Setting and Clinical Trials. Dermatol Ther (Heidelb) 2024; 14:729-743. [PMID: 38451423 PMCID: PMC10965838 DOI: 10.1007/s13555-024-01122-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/14/2024] [Indexed: 03/08/2024] Open
Abstract
INTRODUCTION Secukinumab is an anti-interleukin (IL)-17A monoclonal antibody indicated for multiple immunological disorders. Here, we aim to summarize secukinumab safety in clinical trials (CTs) and post-marketing setting (PMS) until 25 June 2022. METHODS Adverse events (AEs) were summarized with crude reporting rate (RR) per 100 patient-years (PY) in PMS for all reported indications and with exposure-adjusted incident rates (EAIR) per 100 PY in pooled 47 CTs for approved indications. RESULTS Secukinumab exposure totaled 1,159,260 PY in PMS and 27,765 PY in CTs. AEs were mostly (> 80%) non-serious in PMS. EAIR for serious AEs was 7.0/100 PY. Nasopharyngitis (RR 0.59/100 PY, EAIR 16.08/100 PY) and pneumonia (RR 0.14/100 PY, EAIR 0.17/100 PY) were the most common infection and serious infection, respectively. Candida infections (RR 0.20/100 PY, EAIR 2.16/100 PY) were the most common fungal infections. Inflammatory bowel disease (IBD) was observed in PMS (0.14/100 PY) and CTs (0.26/100 PY). Most (76%) patients with prior IBD did not report IBD flare during CTs. PMS monitoring identified paradoxical skin reactions including dyshidrotic eczema (RR 0.006/100 PY) and pyoderma gangrenosum (RR 0.003/100 PY). CONCLUSION Secukinumab safety profile with increased patient exposure remained favorable. Paradoxical skin reactions were identified in post-marketing monitoring.
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Affiliation(s)
- Rui Sun
- Novartis Pharmaceuticals Corporation, Bannockburn, IL, USA
| | | | | | - Mark Lebwohl
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alice B Gottlieb
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Philip J Mease
- Department of Rheumatology, Swedish Medical Center/Providence St. Joseph Health, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Atul Deodhar
- Oregon Health and Science University, Portland, OR, USA
| | - Weibin Bao
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Brian Porter
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Deepa Chand
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
- University of Illinois College of Medicine-Peoria and Children's Hospital of Illinois, Peoria, IL, USA
| | - Victor Dong
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA.
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16
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Abdelghaffar M, Hwang E, Damsky W. Cutaneous Sarcoidosis. Clin Chest Med 2024; 45:71-89. [PMID: 38245372 DOI: 10.1016/j.ccm.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
Sarcoidosis is a multisystem disease that most commonly affects the lungs, lymphatic system, eyes, and skin but any organ may be involved. Cutaneous sarcoidosis most commonly presents as pink-red to red-brown papules and plaques that commonly affect the head and neck. With the skin being readily accessible for evaluation and biopsy, when sarcoidosis is suspected, dermatologic evaluation may be helpful for establishing a definitive diagnosis. Treatment strategy depends on the severity and distribution of skin lesions and should incorporate patient preference and treatment considerations for other organs that may be involved.
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Affiliation(s)
- Mariam Abdelghaffar
- School of Medicine, Royal College of Surgeons in Ireland, Smurfit Building, Beaumont Hospital, Dublin 9, Ireland
| | - Erica Hwang
- Department of Dermatology, Yale School of Medicine, 333 Cedar Street, LCI 501 PO Box 208059, New Haven, CT 06520, USA
| | - William Damsky
- Department of Dermatology, Yale School of Medicine, 333 Cedar Street, LCI 501 PO Box 208059, New Haven, CT 06520, USA; Department of Pathology, Yale School of Medicine, 310 Cedar Street, LH 108, PO Box 208023, New Haven, CT 06520, USA.
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17
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Wang Y, Cui Y, Zheng Z. Adalimumab-Induced Erythrodermic Psoriasis Associated with Alopecia in a Patient with Palmoplantar Pustulosis. Indian J Dermatol 2024; 69:178-180. [PMID: 38841217 PMCID: PMC11149812 DOI: 10.4103/ijd.ijd_155_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
In recent years, with the increased usage of tumour necrosis factor (TNF) inhibitors, more side effects have been revealed. Paradoxical psoriasis, including psoriasis vulgaris, palmoplantar pustulosis, scalp psoriasis and their combinations, is a common adverse effect. However, erythrodermic psoriasis associated with alopecia due to anti-TNF-α is rarely reported in the literature. We report a 44-year-old woman who developed erythrodermic psoriasis associated with diffuse alopecia during her treatment with adalimumab for palmoplantar pustulosis.
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Affiliation(s)
- Ying Wang
- From the Department of Dermatology, China-Japan Friendship Hospital, Beijing, China
| | - Yong Cui
- From the Department of Dermatology, China-Japan Friendship Hospital, Beijing, China
| | - Zhancai Zheng
- From the Department of Dermatology, China-Japan Friendship Hospital, Beijing, China
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18
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Zhang Y, Jiang G. Application of JAK inhibitors in paradoxical reaction through immune-related dermatoses. Front Immunol 2024; 15:1341632. [PMID: 38444845 PMCID: PMC10912518 DOI: 10.3389/fimmu.2024.1341632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/29/2024] [Indexed: 03/07/2024] Open
Abstract
Biologics play a positive and effective role in the treatment of immune-related dermatoses. However, many other immune-related diseases have also manifested along with biologics treatment. Paradoxical reaction through immune-related dermatoses refer to the new onset or exacerbation of other immune-mediated dermatoses (mainly psoriasis and atopic dermatitis) after biologics treatment of inflammatory dermatoses (mainly psoriasis and atopic dermatitis), such as new atopic dermatitis (AD) in psoriasis (PsO) treatment and new PsO in AD treatment. A common genetic background and Inflammatory pathway are possible pathogenesis. Faced with paradoxical reactions, the choice of therapy needs to be directed toward therapies effective for both diseases, such as Janus kinase (JAK) inhibitors. The Janus kinase and signal transducer and activator of transcription (JAK-STAT) pathway plays an important role in the inflammatory pathway, and has been widely used in the treatment of AD and PsO in recent years. This article focuses on JAK inhibitors such as tofacitinib, baricitinib, ruxolitinib, Abrocitinib, upadacitinib, and deucravacitinib, to explore the possible application in treatment of paradoxical reactions. Common side effects, baseline risk factors and safety use of JAK inhibitors were discussed.
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Affiliation(s)
- Yaxin Zhang
- First College for Clinical Medicine, Xuzhou Medical University, Xuzhou, China
- Department of Dermatology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Guan Jiang
- Department of Dermatology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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19
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Klimko A, Olteanu AO, Tieranu I, Orzan OA, Toma CV, Ionescu EM, Preda CM, Tieranu CG. Paradoxical Psoriasis Induced by Ustekinumab: A Comprehensive Review and Case Report. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:106. [PMID: 38256367 PMCID: PMC10818897 DOI: 10.3390/medicina60010106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/25/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Abstract
Ustekinumab (UST), a biologic agent targeting interleukin-12 and interleukin-23, is widely used in the management of psoriasis and Crohn's disease. Despite its efficacy, there have been instances of paradoxical psoriasis induction or exacerbation in some patients during UST therapy. This paper offers a comprehensive review of reported cases of UST-induced paradoxical psoriasis, including a case from our clinic. We focus on a 39-year-old female patient with a history of long-standing Crohn's disease who developed a psoriasiform rash, as confirmed by biopsy, while undergoing UST treatment. The patient's clinical journey, from initial diagnosis through the complexities of treatment adjustments due to various complications including drug-induced lupus and the subsequent onset of psoriatic manifestations, provides insight into the challenges encountered in the clinical management of such cases. This review emphasizes the necessity for clinicians to recognize the possibility of paradoxical psoriasis in patients receiving UST treatment and calls for further research to better understand this phenomenon and devise effective management strategies.
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Affiliation(s)
- Artsiom Klimko
- Laboratory of Molecular Neuro-Oncology, Department of Neurology, University Hospital Zurich, 8091 Zürich, Switzerland;
| | - Andrei Ovidiu Olteanu
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.O.O.); (E.M.I.); (C.M.P.); (C.G.T.)
- Department of Gastroenterology, Elias Emergency University Hospital, 011461 Bucharest, Romania
| | - Ioana Tieranu
- Department of Pediatrics, “Maria Sklodowska Curie” Clinical Emergency Hospital for Children, 077120 Bucharest, Romania;
| | - Olguta Anca Orzan
- Department of Dermatology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Dermatology, Elias Emergency University Hospital, 011461 Bucharest, Romania
| | - Cristian Valentin Toma
- Department of Inovation and e-Health, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Elena Mirela Ionescu
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.O.O.); (E.M.I.); (C.M.P.); (C.G.T.)
- Department of Gastroenterology, Elias Emergency University Hospital, 011461 Bucharest, Romania
| | - Carmen Monica Preda
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.O.O.); (E.M.I.); (C.M.P.); (C.G.T.)
- Department of Gastroenterology, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Cristian George Tieranu
- Department of Gastroenterology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.O.O.); (E.M.I.); (C.M.P.); (C.G.T.)
- Department of Gastroenterology, Elias Emergency University Hospital, 011461 Bucharest, Romania
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20
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Mori Y, Izumiyama T, Otsuka K, Kanabuchi R, Yamamoto J, Sekine M, Mori N, Asano Y, Aizawa T. Pyoderma gangrenosum after surgery for forefoot deformity in a patient with rheumatoid arthritis: A case report. Mod Rheumatol Case Rep 2023; 8:11-15. [PMID: 37638693 DOI: 10.1093/mrcr/rxad051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/29/2023] [Accepted: 08/22/2023] [Indexed: 08/29/2023]
Abstract
Pyoderma gangrenosum (PG) is a rare inflammatory skin disease characterised by skin ulcers that are associated with autoimmune diseases. Although the effectiveness of immunosuppression with glucocorticoids and tumour necrosis factor inhibitors in treating PG has been reported, the utility of negative-pressure wound therapy (NPWT) for severe ulcerative lesions in patients with PG remains controversial. Herein, we report the case of a 76-year-old woman with rheumatoid arthritis who developed PG after undergoing surgery for a forefoot deformity. The patient showed improvement in deep ulcer lesions through NPWT while receiving treatment with abatacept and systemic glucocorticoids. Subsequent topical glucocorticoid therapy led to the remission of the PG. This case suggests that NPWT, when used under immunosuppressive conditions, does not exacerbate the pathergy and may be beneficial for treating severe ulcerative PG.
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Affiliation(s)
- Yu Mori
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takuya Izumiyama
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuaki Otsuka
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ryuichi Kanabuchi
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Yamamoto
- Department of Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Mana Sekine
- Department of Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Naoko Mori
- Department of Radiology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yoshihide Asano
- Department of Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshimi Aizawa
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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21
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Tang X, Li Q, Zhou Y, Zheng X, Zhou C, Hu Y, Wang P, Chen A, Huang K. Predictive factors of atopic-like dermatitis induced by IL-17A inhibitors in patients with psoriasis: A 2-year follow-up study. J Eur Acad Dermatol Venereol 2023; 37:2509-2516. [PMID: 37528440 DOI: 10.1111/jdv.19394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/30/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND Atopic-like dermatitis (ALD) is a common side effect of interleukin-17A (IL-17A) inhibitors. OBJECTIVE To determine the prevalence, risk factors, outcomes and treatment of ALD in a cohort of psoriasis patients treated with IL-17A inhibitors. METHODS This retrospective study included 226 psoriasis patients treated with an IL-17A inhibitor in our dermatology department between July 2020 and July 2022. The patients were reviewed over 2 years. A logistic regression model in rare events data (relogit) was used to predict the risk factors for ALD. RESULTS Of the 226 patients, 14 had ALD. Data including age, body mass index, IL-17A inhibitor use, personal and family history of atopic disease, pet ownership history, and immunoglobulin E (IgE) levels were analysed using the relogit regression model. It indicated a personal history of atopic disease (odd ratio [OR] 27.830, 95% confidence interval [CI] 3.801-203.770; p = 0.001) and elevated IgE levels (OR 5.867, 95% CI 1.131-30.434; p = 0.035) as independent predictors of incident ALD. In one patient, anti-IL-17A therapy was discontinued, and treatment was switched to tofacitinib. Thirteen patients who continued with IL-17A inhibitor were treated with topical therapy and/or antihistamines, and their ALD was partially or completely resolved. CONCLUSION In this study, the incidence rate of ALD was 6.19%. Elevated IgE levels and a personal history of atopic disease were found to be the risk factors for ALD. Our study findings suggest that treatment should be provided based on the severity of psoriasis and incident ALD. Prior to treatment, psoriasis patients who have the risk factors for ALD should be informed of the possible development of ALD, and alternative psoriatic therapeutic options should be considered if severe ALD develops.
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Affiliation(s)
- Xin Tang
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qian Li
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Zhou
- College of Traditional Chinese Medicine of Chongqing Medical University, Chongqing, China
| | - Xuyu Zheng
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Cui Zhou
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yulian Hu
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ping Wang
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Aijun Chen
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kun Huang
- Department of Dermatology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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22
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Vignoli CA, Gargiulo L, Sanna F, Narcisi A, Costanzo A. Adalimumab-induced paradoxical pustular psoriasis and alopecia successfully treated with ixekizumab in a patient affected by hidradenitis suppurativa. J DERMATOL TREAT 2023; 34:2256905. [PMID: 37705359 DOI: 10.1080/09546634.2023.2256905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 09/04/2023] [Indexed: 09/15/2023]
Affiliation(s)
- Carlo Alberto Vignoli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Luigi Gargiulo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Federica Sanna
- Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | | | - Antonio Costanzo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, Italy
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23
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Jesenak M, Diamant Z, Simon D, Tufvesson E, Seys SF, Mukherjee M, Lacy P, Vijverberg S, Slisz T, Sediva A, Simon HU, Striz I, Plevkova J, Schwarze J, Kosturiak R, Alexis NE, Untersmayr E, Vasakova MK, Knol E, Koenderman L. Eosinophils-from cradle to grave: An EAACI task force paper on new molecular insights and clinical functions of eosinophils and the clinical effects of targeted eosinophil depletion. Allergy 2023; 78:3077-3102. [PMID: 37702095 DOI: 10.1111/all.15884] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/21/2023] [Accepted: 08/27/2023] [Indexed: 09/14/2023]
Abstract
Over the past years, eosinophils have become a focus of scientific interest, especially in the context of their recently uncovered functions (e.g. antiviral, anti-inflammatory, regulatory). These versatile cells display both beneficial and detrimental activities under various physiological and pathological conditions. Eosinophils are involved in the pathogenesis of many diseases which can be classified into primary (clonal) and secondary (reactive) disorders and idiopathic (hyper)eosinophilic syndromes. Depending on the biological specimen, the eosinophil count in different body compartments may serve as a biomarker reflecting the underlying pathophysiology and/or activity of distinct diseases and as a therapy-driving (predictive) and monitoring tool. Personalized selection of an appropriate therapeutic strategy directly or indirectly targeting the increased number and/or activity of eosinophils should be based on the understanding of eosinophil homeostasis including their interactions with other immune and non-immune cells within different body compartments. Hence, restoring as well as maintaining homeostasis within an individual's eosinophil pool is a goal of both specific and non-specific eosinophil-targeting therapies. Despite the overall favourable safety profile of the currently available anti-eosinophil biologics, the effect of eosinophil depletion should be monitored from the perspective of possible unwanted consequences.
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Affiliation(s)
- Milos Jesenak
- Department of Clinical Immunology and Allergology, University Teaching Hospital in Martin, Martin, Slovak Republic
- Department of Paediatrics, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Teaching Hospital in Martin, Martin, Slovak Republic
- Department of Pulmonology and Phthisiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Teaching Hospital in Martin, Martin, Slovak Republic
| | - Zuzana Diamant
- Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund University, Lund, Sweden
- Department Microbiology Immunology & Transplantation, KU Leuven, Catholic University of Leuven, Leuven, Belgium
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | - Dagmar Simon
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ellen Tufvesson
- Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund University, Lund, Sweden
| | - Sven F Seys
- Laboratory of Clinical Immunology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Manali Mukherjee
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- The Firestone Institute for Respiratory Health, Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada
| | - Paige Lacy
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Susanne Vijverberg
- Amsterdam UMC Location University of Amsterdam, Pulmonary Diseases, Amsterdam, The Netherlands
| | - Tomas Slisz
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | - Anna Sediva
- Department of Immunology, 2nd Faculty of Medicine, Charles University, Motol University Hospital, Prague, Czech Republic
| | - Hans-Uwe Simon
- Institute of Pharmacology, University of Bern, Bern, Switzerland
- Institute of Biochemistry, Brandenburg Medical School, Neuruppin, Germany
| | - Ilja Striz
- Department of Clinical and Transplant Immunology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jana Plevkova
- Department of Pathophysiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Jurgen Schwarze
- Child Life and Health and Centre for Inflammation Research, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Radovan Kosturiak
- Department of Paediatrics, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Teaching Hospital in Martin, Martin, Slovak Republic
- Outpatient Clinic for Clinical Immunology and Allergology, Nitra, Slovak Republic
| | - Neil E Alexis
- Center for Environmental Medicine, Asthma and Lung Biology, Department of Paediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Eva Untersmayr
- Institute of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Martina Koziar Vasakova
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
| | - Edward Knol
- Department Center of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department Dermatology/Allergology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leo Koenderman
- Department Center of Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department Pulmonary Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
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24
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Chircop I, Guindolet D, Battistella M, Martinez-Vinson C, Bourrat E. Paradoxical inflammatory blepharitis in a patient with Crohn's disease. J AAPOS 2023; 27:377-378. [PMID: 37871794 DOI: 10.1016/j.jaapos.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/24/2023] [Accepted: 08/28/2023] [Indexed: 10/25/2023]
Abstract
We report the case of a 15-year-old boy with severe inflammatory blepharitis who was being treated with a TNFα inhibitor for Crohn's disease (CD). This case shows the potential utility of a skin biopsy in distinguishing metastatic CD associated with granulomatous blepharitis from a paradoxical blepharitis induced by anti-TNFα. It also demonstrates that ustekinumab can be considered in patients with CD who cannot tolerate TNFα inhibitors because of cutaneous paradoxical reactions.
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Affiliation(s)
- Inès Chircop
- Department of Dermatology, Hôpital Edouard Herriot, Lyon, France.
| | - Damien Guindolet
- Department of Ophthalmology, Fondation A. de Rothschild, AP-HP, Paris, France
| | - Maxime Battistella
- Department of Pathology, Hôpital Saint-Louis, AP-HP, Paris, France; Inserm HIPI U976, team 1: onco-dermatology and therapies
| | | | - Emmanuelle Bourrat
- Department of General Pediatrics, Infectious Disease and Internal Medicine, Hôpital Robert Debré, AP-HP, Paris, France
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25
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Lu J, Lu Y. Paradoxical psoriasis: The flip side of idiopathic psoriasis or an autocephalous reversible drug reaction? J Transl Autoimmun 2023; 7:100211. [PMID: 37731549 PMCID: PMC10507642 DOI: 10.1016/j.jtauto.2023.100211] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/21/2023] [Accepted: 09/05/2023] [Indexed: 09/22/2023] Open
Abstract
Psoriasis is a common, chronic skin disease that results mainly from the complex interplay between T cells, dendritic cells, and inflammatory cytokines including TNF-α, IL-17, IL-12, and IL-23. Successful therapy with anti-cytokine antibodies has proved the importance of these key cytokines, especially TNF-α. During the anti-TNF-α treatment of classical idiopathic psoriasis, a small portion of patients develop new psoriasiform lesions. This contradictory phenomenon was named paradoxical psoriasis which resembles idiopathic psoriasis clinically but presents overlapped histological patterns and distinct immunological processes. In this review, we discuss the differences between idiopathic psoriasis and paradoxical psoriasis with an emphasis on their innate immunity, as it is predominant in paradoxical psoriasis which exhibits type I IFN-mediated immunity without the activation of autoreactive T cells and memory T cells. We also put up an instructive algorithm for the management of paradoxical psoriasis. The decision on drug discontinuation or switching of biologics should be made based on the condition of underlying diseases and the severity of lesions.
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Affiliation(s)
- Jiawei Lu
- Department of Dermatology, The First Affiliated Hospital, Nanjing Medical University, Nanjing, PR China
| | - Yan Lu
- Department of Dermatology, The First Affiliated Hospital, Nanjing Medical University, Nanjing, PR China
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26
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Yagiz B, Lermi N, Coskun BN, Dalkilic E, Kiraz S, Erden A, Ertenli I, Duran E, Bilgin E, Yılmaz R, Ateş A, Tufan A, Küçük H, Mercan R, Cinaklı H, Akar S, Yaşar Bilge NŞ, Kaşifoglu T, Türk SM, Gonullu EO, Bes C, Alpay Kanitez N, Emmungil H, Kalyoncu U, Pehlivan Y. The predictors of paradoxical reactions, especially psoriasis, to biologic therapy-findings from the TReasure database: a 5-year follow-up study. Rheumatology (Oxford) 2023; 62:3962-3967. [PMID: 37354493 DOI: 10.1093/rheumatology/kead318] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 04/27/2023] [Accepted: 05/07/2023] [Indexed: 06/26/2023] Open
Abstract
OBJECTIVES The objectives of this study were to assess the clinical characteristics, predictive factors, and practical algorithms of paradoxical reactions (PRs), specifically paradoxical psoriasis (PP). METHODS The TReasure database is a web-based prospective observational cohort comprised of patients with RA and SpA from 17 centres around Turkey since 2017. A cohort study and a case-control study nestled within the cohort were identified. RESULTS In total, 2867 RA and 5316 SpA patients were evaluated. The first biologic agent was found to have caused PRs in 60% of the 136 patients (1.66%) who developed the PRs. The median time interval between the PRs and biological onset was 12 months (range 1-132 months, mean 21 months). The most common types of PP, constituting 92.6% of PRs, were pustular (60.3%) and palmoplantar (30.9%). Adalimumab (30.9%), infliximab (19%) and etanercept (17.4%) were the most common agents causing the PP. In the treatment of most PP patients (73.2%), switching biologic agents was favoured, with TNF inhibitor (TNFi) chosen in 46.03% and non-TNFi in 26.9% of cases. The three most frequently selected drugs were etanercept (24.6%), secukinumab (9.5%) and adalimumab (8.7%). Only 5.17% of patients who switched to another TNFi showed progression. The odds ratios (s) for SSZ, HCQ, and LEF use were significantly higher in RA controls than in PP patients (P = 0.033, OR = 0.15; P = 0.012, OR = 0.15; and P = 0.015, OR = 0.13, respectively). In the PP group with SpA, the number of smokers was significantly higher (P = 0.003, OR: 2.0, 95% CI: 1.05, 3.81). CONCLUSION Contrary to expectations based on earlier research suggesting that paradoxical reactions develop with the class effect of biological agents, the response of patients who were shifted to another TNFi was favourable.
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Affiliation(s)
- Burcu Yagiz
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Nihal Lermi
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Belkis N Coskun
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Ediz Dalkilic
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Sedat Kiraz
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Abdulsamet Erden
- Division of Rheumatology, Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
| | - Ihsan Ertenli
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Emine Duran
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Emre Bilgin
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Recep Yılmaz
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Aşkın Ateş
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Abdurrahman Tufan
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Hamit Küçük
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ridvan Mercan
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Namık Kemal University, Tekirdağ, Turkey
| | - Haluk Cinaklı
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, İzmir Kâtip Çelebi University, İzmir, Turkey
| | - Servet Akar
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, İzmir Kâtip Çelebi University, İzmir, Turkey
| | - Nazife Ş Yaşar Bilge
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Timucin Kaşifoglu
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Sümeyye M Türk
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Emel Orge Gonullu
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Sakarya University, Sakarya, Turkey
| | - Cemal Bes
- University of Health Sciences, Department of Rheumatology, Çam and Sakura City Hospital, İstanbul, Turkey
| | - Nilufer Alpay Kanitez
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Koc University, İstanbul, Turkey
| | - Hakan Emmungil
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Trakya University, Edirne, Turkey
| | - Umut Kalyoncu
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Yavuz Pehlivan
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Uludağ University, Bursa, Turkey
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27
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Alnaqbi KA, Al Zeyoudi J, Fazal F, Alhaj OM, Jassim I, Albreiki FA. Paradoxical Psoriasis and Worsening Spondylitis Due to Secukinumab in a Patient With Ankylosing Spondylitis: A Case Report and Literature Review. Cureus 2023; 15:e50726. [PMID: 38111814 PMCID: PMC10726796 DOI: 10.7759/cureus.50726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2023] [Indexed: 12/20/2023] Open
Abstract
Axial spondyloarthritis (axSpA) is an autoimmune disease primarily affecting the axial skeleton, with associated extra-musculoskeletal manifestations. Treatment strategies targeting cytokines tumor necrosis factor-alpha (TNF-α) and interleukin 17 (IL-17) have proven effective. However, paradoxical reactions, including paradoxical psoriasis and arthritis, have been reported in axSpA patients receiving TNF-α inhibitors. IL-17 inhibitors have been used as an alternative treatment option, but paradoxical reactions have also been rarely observed. This case report presents a 45-year-old man with axSpA who responded to infliximab for six years before discontinuing it due to secondary failure. After the washout period of infliximab, he was started on secukinumab but developed paradoxical psoriasis and worsening of inflammatory back pain after receiving the second loading dose which necessitated replacing it with upadacitinib. Complete resolution of paradoxical psoriasis and significant improvement in his back pain after three months ensued. This case contributes to understanding the complex dynamics in treating axSpA and managing paradoxical reactions.
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Affiliation(s)
- Khalid A Alnaqbi
- Internal Medicine, Tawam Hospital and College of Medicine & Health Sciences, United Arab Emirates University, Al Ain, ARE
- Internal Medicine/Rheumatology, Tawam Hospital, Al Ain, ARE
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28
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Zhang C, Kang T, Qian T, Ma M, Hou X, Li C. Secukinumab-Induced Alopecia Areata Successfully Treated with Tofacitinib in a Patient with Palmoplantar Pustulosis. Clin Cosmet Investig Dermatol 2023; 16:2879-2883. [PMID: 37869531 PMCID: PMC10588803 DOI: 10.2147/ccid.s430156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 09/30/2023] [Indexed: 10/24/2023]
Abstract
Secukinumab, a monoclonal antibody targeting interleukin-17 (IL-17), has exhibited encouraging results in the therapeutic management of palmoplantar pustulosis (PPP). The development of alopecia areata (AA) is closely related to IL-17, and IL-17A inhibitors were considered as a potential treatment modality. Therefore, the development of AA during secukinumab treatment for PPP is a rare adverse event that has been rarely reported worldwide. Here we report a 35-year-old female patient with PPP who developed AA after completing the induction period of secukinumab treatment. Discontinuing secukinumab and initiating treatment with tofacitinib resulted in a significant improvement in both PPP and AA. The emergence of AA in this patient can be attributed to paradoxical skin reactions associated with IL-17 inhibitors. Tofacitinib appears to alleviate biologic-induced AA during PPP syndrome treatment.
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Affiliation(s)
- Chen Zhang
- Department of Rheumatology, Dongfang Hospital Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Tianlun Kang
- Department of Rheumatology, Dongfang Hospital Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Tangliang Qian
- Department of Rheumatology, Dongfang Hospital Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Mingwei Ma
- School of Clinical Medicine, Peking Union Medical College Hospital (PUMC and CAMS), Beijing, People’s Republic of China
| | - Xiujuan Hou
- Department of Rheumatology, Dongfang Hospital Beijing University of Chinese Medicine, Beijing, People’s Republic of China
| | - Chen Li
- Department of Rheumatology, Fangshan Hospital Beijing University of Chinese Medicine, Beijing, People’s Republic of China
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29
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Dissemond J, Marzano AV, Hampton PJ, Ortega-Loayza AG. Pyoderma Gangrenosum: Treatment Options. Drugs 2023; 83:1255-1267. [PMID: 37610614 PMCID: PMC10511384 DOI: 10.1007/s40265-023-01931-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 08/24/2023]
Abstract
Pyoderma gangrenosum is a rare neutrophilic dermatosis that leads to exceedingly painful ulcerations of the skin. Although the exact pathogenesis is not yet fully understood, various auto-inflammatory phenomena with increased neutrophil granulocyte activity have been demonstrated. Despite the limited understanding of the pathogenesis, it is no longer a diagnosis of exclusion, as it can now be made on the basis of validated scoring systems. However, therapy remains a major multidisciplinary challenge. Various immunosuppressive and immunomodulatory therapies are available for the treatment of affected patients. In addition, concomitant topical pharmacologic therapy, wound management and pain control should always be addressed. Corticosteroids and/or cyclosporine remain the systemic therapeutics of choice for most patients. However, in recent years, there has been an increasing number of studies on the positive effects of biologic therapies such as inhibitors of tumour necrosis factor-α; interleukin-1, interleukin-17, interleukin-23 or complement factor C5a. Biologics have now become the drug of choice in certain scenarios, particularly in patients with underlying inflammatory comorbidities, and are increasingly used at an early stage in the disease rather than in therapy refractory patients.
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Affiliation(s)
- Joachim Dissemond
- Department of Dermatology, Venerology and Allergology, University of Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Angelo V Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale, Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Philip J Hampton
- Department of Dermatology, Newcastle Dermatology, Newcastle Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health & Science, University, Portland, OR, USA
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30
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Derbyshire M, Beatty C, Marks K, Kazlouskaya V. Lichenoid eruption during treatment of atopic dermatitis with dupilumab. Int J Dermatol 2023; 62:1202-1203. [PMID: 36250258 DOI: 10.1111/ijd.16465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/06/2022] [Accepted: 10/07/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Mark Derbyshire
- Norton College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Colleen Beatty
- Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Katherine Marks
- Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Viktoryia Kazlouskaya
- Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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31
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Butala S, Castelo-Soccio L, Seshadri R, Simpson EL, O'Shea JJ, Bieber T, Paller AS. Biologic Versus Small Molecule Therapy for Treating Moderate to Severe Atopic Dermatitis: Clinical Considerations. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1361-1373. [PMID: 36948491 PMCID: PMC10164714 DOI: 10.1016/j.jaip.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 03/05/2023] [Accepted: 03/06/2023] [Indexed: 03/24/2023]
Abstract
The U.S. Food and Drug Administration approval of dupilumab for moderate-to-severe atopic dermatitis shifted the paradigm from use of broad, systemic immunosuppressants to a safer, targeted treatment and led to the emergence of newer interleukin (IL)-4/IL-13 directed biologics and small molecule therapies, namely Janus kinase (JAK) inhibitors (JAKi). Tralokinumab and emerging (not yet approved) lebrikizumab, which both target IL-13, are alternative biologics to dupilumab. The emerging anti-IL-31 receptor nemolizumab is likely to be used second-line to other biologics, primarily for pruritus. Three JAKi are currently in use for treating atopic dermatitis, 2 of which, abrocitinib and upadacitinib, are U.S. Food and Drug Administration-approved. This review provides an in-depth, practical discussion on use of these biologics and JAKi that are approved or have completed phase 3 clinical trials in pediatric patients and adults, comparing the groups of medications based on available efficacy and safety data.
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Affiliation(s)
- Sneha Butala
- Departments of Dermatology and Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Leslie Castelo-Soccio
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Md
| | - Rishi Seshadri
- Department of Dermatology, Oregon Health and Science University, Portland, Ore
| | - Eric L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, Ore
| | - John J O'Shea
- Molecular Immunology and Inflammation Branch, National Institute of Arthritis, Molecular Immunology and Inflammation Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Md
| | - Thomas Bieber
- Department of Dermatology and Allergy, University of Bonn, Bonn, Germany
| | - Amy S Paller
- Departments of Dermatology and Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Ill.
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32
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De Stefano L, Pallavicini FB, Mauric E, Piccin V, Vismara EM, Montecucco C, Bugatti S. Tumor necrosis factor-α inhibitor-related immune disorders. Autoimmun Rev 2023; 22:103332. [PMID: 37062440 DOI: 10.1016/j.autrev.2023.103332] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/13/2023] [Indexed: 04/18/2023]
Abstract
Biotechnological monoclonal antibodies and receptor antagonists capable of targeting specific inflammatory actors, such as cytokines, cytokines receptors, co-stimulatory molecules or leukocyte populations, have emerged as an alternative to conventional therapies for treating systemic inflammatory diseases with immune pathogenesis. However, there is no doubt that, with a frequency that is not exceptionally high but also not negligible, immunotherapies can favour the development of systemic and organ-specific immune-mediated disorders. It has become increasingly evident that interference with a specific immune pathway may favour the activation of opposing compensatory signalling, which may exacerbate underlying subclinical disorders or cause immune-mediated diseases completely different from the underlying disease. The 'compensatory immunological switch' has emerged primarily in patients treated with tumor necrosis factor (TNF) -α inhibitors, the first biological drugs approved for treating systemic inflammatory diseases with immune pathogenesis. In this Review, we describe the clinical features and predisposing factors of the main TNF-α inhibitor-related immune disorders, organising them into subclinical serological autoimmunity, autoimmune disorders other than those for which TNF-α inhibitors are indicated, and paradoxical reactions. We also discuss the underlying pathogenetic mechanisms and precautions for use in the therapeutic management of these patients. Better understanding of the complex phenomenon of the 'compensatory immunological switch', which TNF-α inhibitors and other biological drugs might trigger, can help not only appropriately managing immune-mediated disorders, but also better interpreting the heterogeneity of the pathogenetic mechanisms underlying certain chronic inflammatory conditions that, although different from each other, are arbitrarily placed in the context of overly generic nosological entities.
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Affiliation(s)
- Ludovico De Stefano
- Department of Internal Medicine and Therapeutics, Università di Pavia, Italy; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | | | - Eleonora Mauric
- Department of Internal Medicine and Therapeutics, Università di Pavia, Italy; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Veronica Piccin
- Department of Internal Medicine and Therapeutics, Università di Pavia, Italy; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Enrico Maria Vismara
- Department of Internal Medicine and Therapeutics, Università di Pavia, Italy; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carlomaurizio Montecucco
- Department of Internal Medicine and Therapeutics, Università di Pavia, Italy; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Serena Bugatti
- Department of Internal Medicine and Therapeutics, Università di Pavia, Italy; Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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33
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Öğüt ND. Two paradoxical reactions in a patient with psoriasis and psoriatic arthritis: Adalimumab-induced hidradenitis suppurativa and secukinumab-induced alopecia areata. J Eur Acad Dermatol Venereol 2023; 37:e468-e469. [PMID: 36151938 DOI: 10.1111/jdv.18601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 09/13/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Neslihan Demirel Öğüt
- Department of Dermatology and Venereology, School of Medicine, Uşak University, Uşak, Turkey
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34
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Zhang J, Zhang Y, Yang Z, Cheng D, Zhang H, Wei L, Liu C, Yan F, Li C, Dong G, Wang C, Shi D, Xiong H. Inducible nitric oxide synthase-expressing myeloid-derived suppressor cells regulated by interleukin 35 contribute to the pathogenesis of psoriasis. Front Immunol 2023; 14:1091541. [PMID: 36969174 PMCID: PMC10034090 DOI: 10.3389/fimmu.2023.1091541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/22/2023] [Indexed: 03/12/2023] Open
Abstract
Although psoriasis is classified as a T cell-mediated inflammatory disease, the contribution of myeloid cells to the pathogenesis of psoriasis is not fully understood. In the present study, we demonstrated that the expression of the anti-inflammatory cytokine interleukin-35 (IL-35) was significantly increased in patients with psoriasis with a marked increase in the number of myeloid-derived suppressor cells (MDSCs). Similar results were obtained in an imiquimod-induced psoriasis mouse model. IL-35 reduced the total number of MDSCs and their subtypes in the spleens and psoriatic skin lesions, ameliorating psoriasis. IL-35 also reduced the expression of inducible nitric oxide synthase in MDSCs, although it had no significant effect on interleukin-10 expression. Adoptive transfer of MDSCs from imiquimod-challenged mice aggravated the disease and weakened the effect of IL-35 in the recipient mice. In addition, mice transferred with MDSCs isolated from inducible nitric oxide synthase knockout mice had milder disease than those with wild-type MDSCs. Furthermore, wild-type MDSCs reversed the effects of IL-35, while MDSCs isolated from inducible nitric oxide synthase knockout mice did not affect IL-35 treatment. In summary, IL-35 may play a critical role in the regulation of iNOS-expressing MDSCs in the pathogenesis of psoriasis, highlighting IL-35 as a novel therapeutic strategy for patients with chronic psoriasis or other cutaneous inflammatory diseases.
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Affiliation(s)
- Junfeng Zhang
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, China
- Jining Key Laboratory of Immunology, Jining Medical University, Jining, China
| | - Yunsheng Zhang
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, China
| | - Zhiya Yang
- Department of Dermatology & Laboratory of Medical Mycology, Jining No. 1 People’s Hospital, Jining, Shandong, China
| | - Dalei Cheng
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, China
| | - Hui Zhang
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, China
- Jining Key Laboratory of Immunology, Jining Medical University, Jining, China
| | - Li Wei
- Affiliated Hospital of Jining Medical University, Jining Medical University, Jining, China
| | - Chen Liu
- Department of Dermatology & Laboratory of Medical Mycology, Jining No. 1 People’s Hospital, Jining, Shandong, China
| | - Fenglian Yan
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, China
- Jining Key Laboratory of Immunology, Jining Medical University, Jining, China
| | - Chunxia Li
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, China
- Jining Key Laboratory of Immunology, Jining Medical University, Jining, China
| | - Guanjun Dong
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, China
- Jining Key Laboratory of Immunology, Jining Medical University, Jining, China
| | - Changying Wang
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, China
- Jining Key Laboratory of Immunology, Jining Medical University, Jining, China
| | - Dongmei Shi
- Department of Dermatology & Laboratory of Medical Mycology, Jining No. 1 People’s Hospital, Jining, Shandong, China
- *Correspondence: Huabao Xiong, ; Dongmei Shi,
| | - Huabao Xiong
- Institute of Immunology and Molecular Medicine, Jining Medical University, Jining, China
- *Correspondence: Huabao Xiong, ; Dongmei Shi,
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35
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Covarel L, Pina H, Martin P, Lellig E, Staentzel J, Groshaeny L, Moulinet T, Rumeau C, Pontille F, Campoli P, Vaillant P, Tiotiu A. Challenging diagnosis of granulomatosis after switching mepolizumab by dupilumab for severe asthma. Respir Med Res 2022; 83:100959. [PMID: 36563548 DOI: 10.1016/j.resmer.2022.100959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/25/2022] [Accepted: 09/26/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Lea Covarel
- Department of Pulmonology, University Hospital of Nancy, Nancy, France
| | - Heloise Pina
- Department of Anatomopathology, University Hospital of Nancy, Nancy, France
| | - Pascale Martin
- Department of Pulmonology, Hospital Robert Schuman, Metz, France
| | - Elodie Lellig
- Department of Dermatology, University Hospital of Nancy, Nancy, France
| | - Jean Staentzel
- Department of Pulmonology, University Hospital of Nancy, Nancy, France
| | - Luc Groshaeny
- Department of Pulmonology, University Hospital of Nancy, Nancy, France
| | - Thomas Moulinet
- Department of Internal Medicine, University Hospital of Nancy, Nancy, France
| | - Cecile Rumeau
- ENT Department, University Hospital of Nancy, Nancy, France
| | - Fabien Pontille
- Department of Internal Medicine, University Hospital of Nancy, Nancy, France
| | - Philippe Campoli
- Department of Anatomopathology, University Hospital of Nancy, Nancy, France
| | - Pierre Vaillant
- Department of Pulmonology, University Hospital of Nancy, Nancy, France
| | - Angelica Tiotiu
- Department of Pulmonology, University Hospital of Nancy, Nancy, France; EA 3450 DevAH, Development, Adaptation, Cardio-Respiratory Regulations and Motor Control, University of Lorraine, Nancy, France.
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36
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Camela E, Potestio L, Fabbrocini G, Megna M. Paradoxical reactions to biologicals for psoriasis. Expert Opin Biol Ther 2022; 22:1435-1437. [PMID: 36445319 DOI: 10.1080/14712598.2022.2153593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
- Elisa Camela
- Dermatology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Luca Potestio
- Dermatology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Gabriella Fabbrocini
- Dermatology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Matteo Megna
- Dermatology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
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37
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Li M, Li W. Comment on: 'Eczematous drug eruption in patients with psoriasis under anti-interleukin-17A: does interleukin-22 play a key role?'. Clin Exp Dermatol 2022; 47:2305. [PMID: 36006173 DOI: 10.1111/ced.15386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Mengmeng Li
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Li
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu, China
- Department of Dermatology, Rare Diseases Center, West China Hospital, Sichuan University, Chengdu, China
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38
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Murphy MJ, Leasure AC, Damsky W, Cohen JM. Association of sarcoidosis with psoriasis: a cross-sectional study in the All of Us research program. Arch Dermatol Res 2022; 315:1439-1441. [DOI: 10.1007/s00403-022-02488-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 10/21/2022] [Accepted: 11/17/2022] [Indexed: 11/28/2022]
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39
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Reinhart JP, Aird JL, Stephens MC, Asch S, Orandi AB, Tollefson MM. Tumor necrosis factor-α inhibitor-induced morphea and psoriasiform dermatitis in a pediatric patient with Crohn's disease. Pediatr Dermatol 2022; 40:519-522. [PMID: 36385392 DOI: 10.1111/pde.15182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/18/2022] [Indexed: 11/18/2022]
Abstract
Tumor necrosis factor-alpha inhibitor therapy for inflammatory bowel disease may be associated with paradoxical cutaneous adverse events, most commonly psoriasiform eruptions. We present the case of a pediatric female patient with Crohn's disease who developed multiple concurrent cutaneous eruptions while on infliximab treatment, including morphea, psoriasiform dermatitis, and genital lichen sclerosus. Although refractory to skin-directed treatments, all three conditions resolved upon discontinuation of infliximab, supporting their development as a paradoxical reaction to infliximab therapy.
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Affiliation(s)
- Jacob P Reinhart
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jenna L Aird
- Department of Dermatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael C Stephens
- Department of Pediatric Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sarah Asch
- Hometown Pediatric Dermatology, North Oaks, Minnesota, USA
| | - Amir B Orandi
- Department of Pediatric Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
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40
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Park A, Wong L, Lang A, Kraus C, Anderson N, Elsensohn A. Cutaneous T-cell lymphoma following dupilumab use: a systematic review. Int J Dermatol 2022. [PMID: 36073768 DOI: 10.1111/ijd.16388] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/20/2022] [Accepted: 07/28/2022] [Indexed: 11/30/2022]
Abstract
In recent years, studies have associated dupilumab with unmasking or progression of cutaneous T-cell lymphoma (CTCL). The objective of this study was to synthesize reported cases of CTCL in the setting of dupilumab use. Two independent reviewers conducted a systematic review using PubMed and Embase databases. Twelve studies, of 27 total patients, were included. Dupilumab-associated CTCL was diagnosed on average 7.8 months following dupilumab initiation. Of reports that included body surface area (BSA), 100% had a BSA >50% prior to diagnosis, and the majority of patients were diagnosed at later stages of disease: stage III (4/18) or IV (6/18). Post-dupilumab biopsies revealed a greater density of cells and a predominant lichenoid pattern, compared to various histologic patterns and less cell density in pre-dupilumab biopsies. The majority of TCR gene rearrangement studies were equivocal (20%) or negative (60%), posing a potential diagnostic pitfall. Limitations included lack of standardized data collection and reporting and a small number of studies. We suggest that earlier biopsies, three to four months after initiation of dupilumab, may be helpful for earlier recognition of CTCL in patients who are not improving, progressing, or have morphologic changes on dupilumab.
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Affiliation(s)
- Ariel Park
- Department of Dermatology, Loma Linda University, Loma Linda, CA, USA
| | - Lulu Wong
- Department of Dermatology, Loma Linda University, Loma Linda, CA, USA
| | - Annalise Lang
- Department of Dermatology, Loma Linda University, Loma Linda, CA, USA
| | - Christina Kraus
- Department of Dermatology, University of California, Irvine, Irvine, CA, USA
| | - Nancy Anderson
- Department of Dermatology, Loma Linda University, Loma Linda, CA, USA
| | - Ashley Elsensohn
- Department of Dermatology, Loma Linda University, Loma Linda, CA, USA
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41
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Bataille P, Layese R, Claudepierre P, Paris N, Dubiel J, Amiot A, Sbidian E. Paradoxical reactions and biologic agents: a French cohort study of 9,303 patients. Br J Dermatol 2022; 187:676-683. [PMID: 35770735 DOI: 10.1111/bjd.21716] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/20/2022] [Accepted: 06/26/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Paradoxical reactions (PRs) are defined as the occurrence during biologic therapy of a pathological condition that usually responds to these drugs. OBJECTIVE To estimate the incidence of PRs and identify risk factors. METHODS Multicenter study of the database for the Greater Paris University Hospitals including biological-naïve patients receiving anti-tumor necrosis factor-α, anti-interleukin-12/23, anti-interleukin-17 or anti-α4ß7-integrin agents for psoriasis, inflammatory rheumatism or inflammatory bowel disease (IBD). We used natural language processing algorithms to extract data. A cohort and a case-control study nested in the cohort with controls selected by incidence density sampling was used to identify risk factors. RESULTS Most of the 9,303 included patients (median age 43.0; 53.8% women) presented an IBD (3,773 [40.6%]) or a chronic inflammatory rheumatic disease (3,708 [39.9%]), and 8,487 (91.2%) received anti-TNF-α agents. A total of 293 (3.1%) had a PR. The global incidence rate was 7.6 per 1,000 person-years (95%CI 6.7-8.4). Likelihood of PR was associated with IBD (adjusted OR [aOR] 1.9, 95%CI 1.1-3.2, p=0.021) and a combination of two inflammatory diseases (aOR 6.1, 95%CI 3.6-10.6, p<0.001) and was reduced with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and corticosteroids (aOR 0.6, 95%CI 0.4-0.8, p=0.003; 0.4, 0.2-0.7, p<0.001). CONCLUSION Likelihood of PRs was associated with IBD or a combination of a least two inflammatory diseases. More studies are needed to assess the benefit of systematically adding csDMARDs for such high-risk patients.
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Affiliation(s)
| | - Richard Layese
- Univ Paris Est Creteil, INSERM, IMRB, CEpiA Team, F-94010 Creteil, France.,AP-HP, Hôpital Henri Mondor, Unité de Recherche Clinique (URC Mondor), Creteil, F-94010, France
| | - Pascal Claudepierre
- AP-HP, Hopital Henri-Mondor, Department of Rheumatology, F-94010 Creteil, France
| | - Nicolas Paris
- WIND Department APHP Greater Paris University Hospital
| | - Julien Dubiel
- WIND Department APHP Greater Paris University Hospital
| | - Aurélien Amiot
- AP-HP, Hopital Henri-Mondor, Department of Gastroenterology, F-94010 Creteil, France
| | - Emilie Sbidian
- Univ Paris Est Creteil, EpiDermE, F-94010 Creteil, France.,AP-HP, Hopital Henri-Mondor, Department of Dermatology, F-94010 Creteil, France
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42
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Sano H, Maeda T, Sato R, Shimizu F, Koga M, Kanda T. [Acute sarcoid myopathy and neuropathy aggravated by ustekinumab administration in an elderly woman with psoriasis and systemic sarcoidosis]. Rinsho Shinkeigaku 2022; 62:475-480. [PMID: 35644583 DOI: 10.5692/clinicalneurol.cn-001714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
A 72-year old woman, who had a history of psoriasis and psoriatic arthritis from age of 69, was admitted because of acute progression of dyspnea and generalized muscle weakness after initiation of ustekinumab. She had been diagnosed as having lung and eye sarcoidosis ten months before admission. Nerve conduction studies revealed multiple mononeuropathy and needle electromyography showed myogenic changes with spontaneous activities. Muscle pathology showed non-caseating epithelioid granuloma and high expression of HLA-class I in myofibers. Diagnosis of sarcoid myopathy and neuropathy aggravated by ustekinumab was made, and ustekinumab administration was discontinued, resulting in slight improvement of her respiratory and neuro-muscular symptoms, but her symptoms remained severely disabled. Treatment with oral steroids further improved her clinical symptoms and she became able to walk independently. We considered that ustekinumab inhibited IL-12 and IL-23 signaling, which caused an imbalance in Th1/Th17 differentiation and activation of Th1 cell differentiation, thereby promoting the development of sarcoid myopathy and neuropathy.
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Affiliation(s)
- Hironori Sano
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
| | - Toshihiko Maeda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
| | - Ryota Sato
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
| | - Fumitaka Shimizu
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
| | - Michiaki Koga
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
| | - Takashi Kanda
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine
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43
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Miyagawa F. Pathogenesis of Paradoxical Reactions Associated with Targeted Biologic Agents for Inflammatory Skin Diseases. Biomedicines 2022; 10:biomedicines10071485. [PMID: 35884790 PMCID: PMC9312477 DOI: 10.3390/biomedicines10071485] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/16/2022] [Accepted: 06/21/2022] [Indexed: 11/16/2022] Open
Abstract
Targeted biologic agents have dramatically changed the therapeutic landscape for immune-mediated inflammatory diseases, particularly in rheumatology and dermatology. Their introduction has resulted in a paradigm shift, i.e., they produce significant clinical improvements in most patients with such diseases. Nevertheless, a variety of adverse reactions associated with these agents have been observed, including so-called paradoxical reactions (PRs), which are a new class of adverse events. PRs involve the de novo development or worsening of immune-mediated inflammatory disease during treatment with a targeted biologic agent that is commonly used to treat the idiopathic counterpart of the drug-induced reaction. In addition, the efficacy of biologic agents targeting individual cytokines and the existence of PRs to them have provided proof that cytokines are key drivers of various immune-mediated inflammatory diseases and helped researchers elucidate the molecular pathways underlying the pathophysiology of these diseases. Here, a comprehensive review of the targeted biologic agents used to treat immune-mediated inflammatory diseases, particularly psoriasis and atopic dermatitis, is provided, with a specific focus on biologic agents that inhibit cytokine signaling involving tumor necrosis factor-α, interleukin (IL)-12/23 (p40), IL-17A (and the IL-17 receptor [R]), IL-23 (p19), and the IL-4Rα, and their associated PRs. The characteristic clinical manifestations and potential immunological mechanisms of the PRs induced by these biologic agents are also reviewed.
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Affiliation(s)
- Fumi Miyagawa
- Department of Dermatology, Nara Medical University School of Medicine, Nara 634-8522, Japan
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44
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Damsky W, Wang A, Kim DJ, Young BD, Singh K, Murphy MJ, Daccache J, Clark A, Ayasun R, Ryu C, McGeary MK, Odell ID, Fazzone-Chettiar R, Pucar D, Homer R, Gulati M, Miller EJ, Bosenberg M, Flavell RA, King B. Inhibition of type 1 immunity with tofacitinib is associated with marked improvement in longstanding sarcoidosis. Nat Commun 2022; 13:3140. [PMID: 35668129 PMCID: PMC9170782 DOI: 10.1038/s41467-022-30615-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/05/2022] [Indexed: 01/05/2023] Open
Abstract
Sarcoidosis is an idiopathic inflammatory disorder that is commonly treated with glucocorticoids. An imprecise understanding of the immunologic changes underlying sarcoidosis has limited therapeutic progress. Here in this open-label trial (NCT03910543), 10 patients with cutaneous sarcoidosis are treated with tofacitinib, a Janus kinase inhibitor. The primary outcome is the change in the cutaneous sarcoidosis activity and morphology instrument (CSAMI) activity score after 6 months of treatment. Secondary outcomes included change in internal organ involvement, molecular parameters, and safety. All patients experience improvement in their skin with 6 patients showing a complete response. Improvement in internal organ involvement is also observed. CD4+ T cell-derived IFN-γ is identified as a central cytokine mediator of macrophage activation in sarcoidosis. Additional type 1 cytokines produced by distinct cell types, including IL-6, IL-12, IL-15 and GM-CSF, also associate with pathogenesis. Suppression of the activity of these cytokines, especially IFN-γ, correlates with clinical improvement. Our results thus show that tofacitinib treatment is associated with improved sarcoidosis symptoms, and predominantly acts by inhibiting type 1 immunity.
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Affiliation(s)
- William Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, CT, USA. .,Department of Pathology, Yale School of Medicine, New Haven, CT, USA.
| | - Alice Wang
- grid.47100.320000000419368710Department of Dermatology, Yale School of Medicine, New Haven, CT USA
| | - Daniel J. Kim
- grid.47100.320000000419368710Department of Dermatology, Yale School of Medicine, New Haven, CT USA
| | - Bryan D. Young
- grid.47100.320000000419368710Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT USA
| | - Katelyn Singh
- grid.47100.320000000419368710Department of Dermatology, Yale School of Medicine, New Haven, CT USA
| | - Michael J. Murphy
- grid.47100.320000000419368710Department of Dermatology, Yale School of Medicine, New Haven, CT USA
| | - Joseph Daccache
- grid.47100.320000000419368710Department of Dermatology, Yale School of Medicine, New Haven, CT USA
| | - Abigale Clark
- grid.258405.e0000 0004 0539 5056Kansas City University of Medicine and Biosciences, Kansas City, MO USA
| | - Ruveyda Ayasun
- grid.240324.30000 0001 2109 4251Laura and Isaac Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY USA
| | - Changwan Ryu
- grid.47100.320000000419368710Seciton of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT USA
| | - Meaghan K. McGeary
- grid.47100.320000000419368710Department of Pathology, Yale School of Medicine, New Haven, CT USA
| | - Ian D. Odell
- grid.47100.320000000419368710Department of Dermatology, Yale School of Medicine, New Haven, CT USA ,grid.47100.320000000419368710Department of Immunobiology, Yale School of Medicine, New Haven, CT USA
| | - Ramesh Fazzone-Chettiar
- grid.47100.320000000419368710Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT USA
| | - Darko Pucar
- grid.47100.320000000419368710Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT USA
| | - Robert Homer
- grid.47100.320000000419368710Department of Pathology, Yale School of Medicine, New Haven, CT USA
| | - Mridu Gulati
- grid.47100.320000000419368710Seciton of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT USA
| | - Edward J. Miller
- grid.47100.320000000419368710Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT USA
| | - Marcus Bosenberg
- grid.47100.320000000419368710Department of Dermatology, Yale School of Medicine, New Haven, CT USA ,grid.47100.320000000419368710Department of Pathology, Yale School of Medicine, New Haven, CT USA ,grid.47100.320000000419368710Department of Immunobiology, Yale School of Medicine, New Haven, CT USA
| | - Richard A. Flavell
- grid.47100.320000000419368710Department of Immunobiology, Yale School of Medicine, New Haven, CT USA ,grid.47100.320000000419368710Howard Hughes Medical Institute, Yale University School of Medicine, New Haven, CT USA
| | - Brett King
- Department of Dermatology, Yale School of Medicine, New Haven, CT, USA.
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Townsend CM, Lovegrove F, Khanna R, Wilson AS. Review article: paradoxical psoriasis as a consequence of tumour necrosis factor antagonists in patients with inflammatory bowel disease. Aliment Pharmacol Ther 2022; 55:1379-1388. [PMID: 35312094 DOI: 10.1111/apt.16883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/12/2022] [Accepted: 02/28/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Tumour necrosis factor (TNF) antagonists are an efficacious therapy used in the management of several immune-mediated inflammatory diseases, including inflammatory bowel disease (IBD) and psoriasis. However, since being prescribed more widely, reports of new-onset psoriatic lesions have began to emerge in the literature and are known as paradoxical psoriasis. AIM To review the evidence available in both the dermatology and gastroenterology literature pertaining to the entity known as paradoxical psoriasis as it relates to IBD and to create a comprehensive guide to assist clinicians who treat this challenging patient population. METHODS A literature search was conducted in PubMed to identify manuscripts that presented, discussed or summarised data pertaining to paradoxical psoriasis presenting in individuals with IBD. RESULTS Paradoxical psoriasis is now thought to be a contradictory effect of TNF antagonist therapy leading to psoriatic lesions often within the first year of treatment. The underlying pathogenesis, although not completely understood, is likely related to an imbalance of inflammatory cytokines. The histological appearance, while similar to classical psoriasis, does have unique features. The clinical presentation can vary among patients but often presents during maintenance therapy for inflammatory bowel disease. Treatment options should be determined based upon the severity of the skin lesion, activity of the underlying inflammatory bowel disease and the patient's unique clinical history. CONCLUSIONS The approach to paradoxical psoriasis in IBD should be discussed with a multidisciplinary team to optimise and preserve intestinal disease remission and to ensure the resolution of debilitating skin lesions.
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Affiliation(s)
- Cassandra Marie Townsend
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Fiona Lovegrove
- Department of Medicine, Schulich School of Medicine, Western University, London, Ontario, Canada.,Lovegrove Dermatology, London, Ontario, Canada
| | - Reena Khanna
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada
| | - Aze Suzanne Wilson
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario, Canada.,Division of Clinical Pharmacology, Department of Medicine, Western University, London, Ontario, Canada.,Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
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46
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Tsai YC, Tsai TF. Overlapping Features of Psoriasis and Atopic dermatitis: From Genetics to Immunopathogenesis to Phenotypes. Int J Mol Sci 2022; 23:ijms23105518. [PMID: 35628327 PMCID: PMC9143118 DOI: 10.3390/ijms23105518] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 12/13/2022] Open
Abstract
Psoriasis (PSO) and atopic dermatitis (AD) were once considered to be mutually exclusive diseases, but gradually regarded as a spectrum of disease. Shared genetic loci of both diseases were noted in some populations, including Chinese. Shared immunopathogenesis involving Th17, Th1, Th22 cells, or even IL-13 was found in certain stages or phenotypes. This review discusses the overlapping genetic susceptibility, shared cytokines, immune-mediated comorbidities, and clinical presentations. Overlapping conditions could be classified into mainly PSO lesions with AD features or vice versa, concomitant PSO and AD, or disease transformation as a result of biologics treatment.
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Affiliation(s)
- Ya-Chu Tsai
- Department of Dermatology, Far Eastern Memorial Hospital, New Taipei 220, Taiwan;
| | - Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100, Taiwan
- Correspondence: ; Tel.: +886-23123456 (ext. 65734)
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47
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Megna M, Caiazzo G, Parisi M, Ruggiero A, Capasso G, Mascolo M, Russo D, Gallo L, Fabbrocini G, Napolitano M, Patruno C. Eczematous drug eruption in patients with psoriasis under anti-interleukin-17A: does interleukin-22 play a key role? Clin Exp Dermatol 2022; 47:918-925. [PMID: 34862807 DOI: 10.1111/ced.15052] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/24/2021] [Accepted: 12/03/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Eczematous drug eruption (EDE) is a spongiotic skin reaction in response to systemic medications. To date, EDE has been described in patients treated with anti-interleukin (IL)-17A monoclonal antibodies with a prevalence of 2.2%-12.1%. AIM To describe the clinical and histological features and the skin cytokine milieu in patients with EDE induced by anti-IL-17A biologics. METHODS This was a prospective study, enrolling patients with psoriasis who developed EDE during treatment with two anti-IL-17 biologics, ixekizumab and secukinumab, from June 2019 to April 2021. Skin biopsies were taken from all patients: a 5-mm lesional biopsy (LB) and a 3-mm nonlesional biopsy (NLB). The LB sample was split into two parts, one for histological examination and the other for cytokine profile evaluation. RESULTS During the study period, treatment with an anti-IL-17A drug was given to 289 patients of whom 8 (2.8%) developed EDE during the treatment. Histopathological evaluation suggested a diagnosis of spongiotic dermatitis in all eight patients. Cytokine gene expression showed a predominance of T helper (Th)2/Th22 cytokines in EDE lesions with a large increase in IL-4, IL-22 and S100A7 levels in both LB and NLB samples compared with healthy skin. IL-4, IL-22 and S100A7 were significantly higher in LB compared with NLB samples. IL-26 levels were also significantly increased in both LB and NLB compared with healthy skin, whereas low levels of IL-23A were found in both LB and NLB. CONCLUSION Eczematous drug eruption skin lesions have mainly Th2/Th22 features, with IL-22 playing a major role in their pathogenesis. EDE seems to be the result of an imbalance towards a Th2/Th22 response, secondary to the blockade of IL-17A activity.
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Affiliation(s)
- Matteo Megna
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Napoli, Italy
| | - Giuseppina Caiazzo
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Napoli, Italy
| | - Melania Parisi
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Napoli, Italy
| | - Angelo Ruggiero
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Napoli, Italy
| | - Gianmarco Capasso
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Napoli, Italy
| | - Massimo Mascolo
- Pathology Unit, Department of Advanced Biomedical Sciences, University of Naples Federico II, Napoli, Italy
| | - Daniela Russo
- Pathology Unit, Department of Advanced Biomedical Sciences, University of Naples Federico II, Napoli, Italy
| | - Lucia Gallo
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Napoli, Italy
| | - Gabriella Fabbrocini
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Napoli, Italy
| | - Maddalena Napolitano
- Department of Medicine and Health Sciences Vincenzo Tiberio, University of Molise, Campobasso, Italy
| | - Cataldo Patruno
- Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
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48
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Development of alopecia areata-like reactions in a patient treated with dupilumab. Allergol Int 2022; 71:420-422. [PMID: 35346581 DOI: 10.1016/j.alit.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/01/2022] [Accepted: 02/20/2022] [Indexed: 11/23/2022] Open
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49
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Narla S, Silverberg JI, Simpson EL. Management of inadequate response and adverse effects to dupilumab in atopic dermatitis. J Am Acad Dermatol 2022; 86:628-636. [PMID: 34126094 DOI: 10.1016/j.jaad.2021.06.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/02/2021] [Accepted: 06/07/2021] [Indexed: 02/06/2023]
Abstract
Atopic dermatitis (AD) is a chronic inflammatory skin disease characterized by pruritus, skin pain, and sleep disturbances. Currently, dupilumab is the only systemic therapy and biologic medication approved by the United States Food and Drug Administration for moderate-to-severe AD in adults and children. There is a sparsity of literature available on determining treatment failure with dupilumab and the next steps health care providers can take to treat AD. Individual goals and quality of life and not just body surface area should be considered when defining treatment failure. Possible confounding dermatoses also should be ruled out. Early identification of dupilumab-induced adverse events is important. For most patients, dupilumab can be continued while treatment for the adverse event is initiated. Adjusting the frequency of dupilumab dosing also may be considered in some circumstances. Adjuvant therapies, such as methotrexate, azathioprine, mycophenolate mofetil, cyclosporine, or phototherapy can be added but the safety and efficacy of these combination treatments are not known at this time.
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Affiliation(s)
- Shanthi Narla
- Department of Dermatology, St. Luke's University Health Network, Easton, Pennsylvania
| | - Jonathan I Silverberg
- Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Eric L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon.
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50
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Uysal PI, Gunhan O. De novo pustular psoriasis associated with dupilumab therapy in a young male with the diagnosis of atopic dermatitis. Dermatol Ther 2022; 35:e15399. [PMID: 35194901 DOI: 10.1111/dth.15399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/28/2022] [Accepted: 02/19/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Pinar Incel Uysal
- Department of Dermatology, TOBB ETU Faculty of Medicine, Ankara, TURKEY
| | - Omer Gunhan
- Department of Pathology, TOBB ETU Faculty of Medicine, Ankara, TURKEY
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