Certolizumab Pegol-Induced Folliculitis-Like Lichenoid Sarcoidosis in a Patient with Rheumatoid Arthritis

Certolizumab-induced lichenoid eruption in a patient with rheumatoid arthritis

Certolizumab is a monoclonal antibody against tumour necrosis factor-alpha (TNF-α) commonly used in rheumatologic conditions such as rheumatoid arthritis. Skin rashes are an uncommon side effect with few cases of lichenoid drug eruption reported in the literature. We describe a patient with rheumatoid arthritis who presented 6 weeks after initiating certolizumab pegol. Physical examination showed pink-to-violaceous papules on her upper and lower extremities. Biopsy confirmed a lichenoid drug eruption. The medication was discontinued and she was treated with topical steroids and a calcineurin inhibitor, with resolution of her lesions. Clinicians should be cognizant of such adverse reactions to TNF-α inhibitors and keep drug-induced lichenoid eruptions on the differential. Lichenoid eruptions induced by certolizumab pegol may affect the skin and/or mucous membranes. While most cases occur within weeks to months of starting therapy, eruptions may occur years after treatment initiation, underscoring the importance of a thorough review of medications.

A rare case of follicular sarcoidosis

The article is devoted to a rare variant of skin sarcoidosis the so-called follicular sarcoidosis. According to the literature, the follicular form of sarcoidosis is extremely rare, several isolated cases are described in foreign literature, there are no publications in the russian literature. A 30-year-old female patient came to the clinic of the Military Medical Academy with a skin rash of the upper extremities, trunk and neck that lasted for one year. Anamnesis: repeated use of topical corticosteroids for the treatment with a temporary positive effect. The skin process was represented by common follicular papules; a histological examination of one of the elements revealed granulomas of the sarcoid type, which were located perifolliculary, mainly around the infundibular sections of the hair follicles. The rash resolved after a course of external corticosteroid therapy. The clinical case described by us illustrates the need for histological examination to verify the diagnosis.

Systemic Sarcoidosis Associated with Certolizumab Pegol Treatment for Rheumatoid Arthritis: A Case Report and Review of the Literature

A 69-year-old woman presented with appetite loss, fatigue, and a low-grade fever. She had been receiving certolizumab pegol for rheumatoid arthritis for six years. Computed tomography of the chest showed multiple micronodules in both lungs and bilateral hilar and mediastinal lymphadenopathy. An ophthalmic examination showed the findings of uveitis. Lymphocytosis with an increased CD4/CD8 ratio was seen in the bronchoalveolar lavage fluid. Video-assisted thoracoscopic biopsy specimens obtained from the right lung and a right hilar lymph node showed noncaseous epithelioid cell granulomas. Anti-tumor necrosis factor-α-induced sarcoidosis was diagnosed, and she was successfully treated with cessation of certolizumab pegol and systemic corticosteroid therapy.

Paradoxical Skin Reaction to Certolizumab, an Overlap of Pyoderma Gangrenosum and Psoriasis in a Young Woman Treated for Ankylosing Spondylitis: Case Report with Literature Review

Introduction

Biologic agents form an indispensable part of modern therapeutic regimens for the treatment of severe inflammatory diseases, especially in the fields of rheumatology, dermatology and gastroenterology. They are favoured by both physicians and patients due to their high effectiveness, good patient tolerance and safety. However, interference in the regulation and dynamics of inflammatory cytokines can on occasion lead to an onset of a dermatological condition also known as paradoxical skin reaction. Here, we present a case of paradoxical skin reaction induced by certolizumab.

Case Report

A young woman with ankylosing spondylitis developed a severe and complex cutaneous reaction after 6 months of otherwise successful treatment with certolizumab. The diagnosis of a rare paradoxical cutaneous reaction post anti-tumour necrosis factor alpha treatment was based on overlapping features of pyoderma gangrenosum and palmoplantar pustular psoriasis. Alopecia developed and there was also nail involvement. Treatment proved to be challenging as the disease did not remit after the patient ceased treatment with certolizumab. The patient was started on a combination of secukinumab and methotrexate to control the symptoms, with a promising outcome.

Conclusion

Paradoxical skin reactions are an emerging clinical entity that require further research in order to establish risk factors and best personalized treatment.