A case of abatacept associated neutrophilic dermatosis and a review of the literature

Abatacept-Induced Panniculitis With Necrobiosis Lipoidica-Like Features in a Patient With Rheumatoid Arthritis

We present a 57-year-old female with a past medical history of rheumatoid arthritis, hypertension, and hypothyroidism who presented with poorly demarcated, nonblanching, painful, erythematous nodules on the bilateral lower legs for two weeks. The patient recently switched from infliximab to abatacept infusions, and skin eruptions presented 53 days from her initial abatacept infusion. A 5 mm punch biopsy of the left anterior upper leg in the zone of involvement showed a deep dermal granulomatous infiltrate with associated eosinophils and a vaguely horizontally palisaded pattern with necrobiosis. The granulomatous inflammation extended into the subcutaneous septae with a widening of the septae, edema, and lipomembranous fat necrosis. The patient was started on naproxen 500 mg PO BID and halobetasol propionate 0.05% lotion BID. Concomitantly, she was started on a four-day course of oral prednisone 10 mg PO daily and restarted infliximab infusions on the third day of prednisone treatment. At her initial infliximab infusions, she received one dose of solumedrol 40 mg and diphenhydramine 50 mg. The eruption resolved 21 days after the initial presentation. The present case is unique from the nine other cutaneous eruptions described after initiating abatacept therapy. Less than 10 cases of cutaneous panniculitides have been reported as adverse reactions to abatacept, with the most common reactions associated with oral contraceptives, nonsteroidal anti-inflammatory drugs, antibiotics, and leukotriene modifying agents. This case underscores the variety of histological findings in drug-induced panniculitis, highlighting the possibility of a drug reaction in a patient with rheumatological disease presenting with panniculitis.

Neutrophilic dermatoses: Pathogenesis, Sweet syndrome, neutrophilic eccrine hidradenitis, and Behçet disease

Neutrophilic dermatoses are a heterogeneous group of inflammatory skin disorders that present with unique clinical features but are unified by the presence of a sterile, predominantly neutrophilic infiltrate on histopathology. The morphology of cutaneous lesions associated with these disorders is heterogeneous, which renders diagnosis challenging. Moreover, a thorough evaluation is required to exclude diseases that mimic these disorders and to diagnose potential associated infectious, inflammatory, and neoplastic processes. While some neutrophilic dermatoses may resolve spontaneously, most require treatment to achieve remission. Delays in diagnosis and treatment can lead to significant patient morbidity and even mortality. Therapeutic modalities range from systemic corticosteroids to novel biologic agents, and the treatment literature is rapidly expanding. The first article in this continuing medical education series explores the pathogenesis of neutrophilic dermatoses and reviews the epidemiology, clinical and histopathologic features, diagnosis, and management of Sweet syndrome, neutrophilic eccrine hidradenitis, and Behçet disease.

Cutaneous Manifestations of Reactions to Biologics

PURPOSE OF REVIEW

The goal of this paper is to review the major adverse cutaneous reactions that have been reported to the most commonly used biologics.

RECENT FINDINGS

Anti-TNF agents and immune checkpoint inhibitors have significant, immune-mediated cutaneous manifestations that can necessitate discontinuation. Anti-TNF agents, IL-6 inhibitors, and IL-12/23 inhibitors can paradoxically cause psoriasis flares or unmask previously undiagnosed psoriasis. IL-17 inhibitors are unique in increasing risk for Candida infections. Benign injection site reactions, non-specific rash, cellulitis, and hypersensitivity reactions are relatively common adverse events. A wide variety of cutaneous reactions caused by biologics have been reported, ranging from benign injection site reactions to life-threatening cutaneous reactions necessitating discontinuation of the implicated biologic agent.