Case and research letters
Episode of Pustular Psoriasis After a Tuberculin Test in a Patient With Plaque Psoriasis on Treatment With Etanercept
Brote de psoriasis pustulosa después de la prueba de la tuberculina en un paciente con psoriasis en placas en tratamiento con etanercept
R.M. Guinovart
, C. Ferrándiz, I. Bielsa, J.M. Carrascosa
Corresponding author
Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Badalona, Universitat Autònoma de Barcelona, Badalona, Barcelona
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Guinovart, C. Ferrándiz, I. Bielsa, J.M. Carrascosa" "autores" => array:4 [ 0 => array:4 [ "nombre" => "R.M." "apellidos" => "Guinovart" "email" => array:1 [ 0 => "rosa_guinovart@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Ferrándiz" ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Bielsa" ] 3 => array:2 [ "nombre" => "J.M." "apellidos" => "Carrascosa" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Dermatología, Hospital Universitari Germans Trias i Pujol, Badalona, Universitat Autònoma de Barcelona, Badalona, Barcelona" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Brote de psoriasis pustulosa después de la prueba de la tuberculina en un paciente con psoriasis en placas en tratamiento con etanercept" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1182 "Ancho" => 1580 "Tamanyo" => 248714 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pustules on the residual psoriasis plaques.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Despite the efficacy of tumor necrosis factor (TNF) α inhibitors in the management of moderate to severe psoriasis, some adverse effects associated with psoriasis have been reported in patients undergoing treatment with these biologic agents. The most frequently described effects are new-onset psoriasis in patients with no history of the disease and exacerbation or modification of the morphology of a previously diagnosed psoriasis. A large percentage of new-onset psoriasis is in the form of pustular psoriasis, mainly affecting the palms and soles,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> whereas guttate psoriasis is more common in patients with a prior history of the disease.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> We describe a patient with plaque psoriasis that was being treated with etanercept, who presented an exacerbation due to a change in the morphology of the disease to generalized pustular psoriasis, immediately after undergoing a purified protein derivative (PPD) tuberculin skin test, suggesting an association between the two events.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 49-year-old man with a 29-year history of plaque psoriasis, which had previously been treated with topical corticosteroids; he had undergone 2 years of treatment with acitretin until the therapy was stopped due to dyslipemia. In 2005, with a psoriasis area and severity (PASI) score of 19.8, the patient began treatment with etanercept (25<span class="elsevierStyleHsp" style=""></span>mg twice a week), with an excellent response in the first year. Four months after stopping treatment, the patient suffered a relapse (PASI score, 22) and it was therefore decided to reinstate treatment with etanercept at a dosage of 50<span class="elsevierStyleHsp" style=""></span>mg twice a week for the first 12 weeks, with a subsequent maintenance dosage of 25<span class="elsevierStyleHsp" style=""></span>mg twice a week. The patient's condition was adequately controlled during the initial 3 years of treatment, with a mean PASI score of 3. However, 24<span class="elsevierStyleHsp" style=""></span>hours after undergoing the routine annual PPD test, pustules developed on the residual psoriasis plaques (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>); 48<span class="elsevierStyleHsp" style=""></span>hours later, the rash had evolved into generalized pustular psoriasis, mainly involving the extremities (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Bacterial cultures were negative and histology was compatible with a diagnosis of pustular psoriasis. Treatment with etanercept was suspended due to a suspected paradoxical reaction with the drug, and the patient was started on ciclosporin (4<span class="elsevierStyleHsp" style=""></span>mg/kg/d). The episode was brought under control after 2 weeks (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Treatment was then started with ustekinumab, while the dosage of ciclosporin was gradually reduced.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Psoriasis may be paradoxically exacerbated or induced by the 3 available anti-TNF agents.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a> However, etanercept is more usually associated with exacerbations of previously existing psoriasis, whereas monoclonal antibodies (infliximab and adalimumab) mainly induce an initial outbreak of psoriasis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The mechanisms that cause these paradoxical effects are unknown. No trigger factors have been identified in pustular psoriasis of the palms and soles and a potential causal role of TNF-α inhibitors has been suggested. Generalized pustular psoriasis has been associated with factors such as pregnancy, infections, severe skin irritation caused by topical medication, and some drugs (lithium, salicylates, indomethacin, and various β-blockers). On the other hand, generalized pustular rashes in patients with stable plaque psoriasis have been linked to ultraviolet light, infections, and allergic contact dermatitis,<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> but have not been reported in the literature in patients with psoriasis being treated with anti-TNF-α agents. In our patient, the acute outbreak only 24<span class="elsevierStyleHsp" style=""></span>hours after performing the PPD skin test and the continuous blanching achieved in the previous 3 years of treatment with etanercept suggests a synergistic effect of the combination of the biologic agent and the diagnostic test. Generalized pustular psoriasis as a complication of PPD is not reported in the literature, but a case has been described of a patient with a history of plaque psoriasis, who was receiving no systemic treatment when the tuberculin skin test was performed; the patient presented a pustular exacerbation of the psoriasis after the skin test was performed.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The pustular episode in our patient could also be considered as an atypical presentation of acute exanthematous pustulosis due to the tuberculin skin test. However, the histology findings and the coexistence of some typical plaque psoriasis lesions with the pustular rash make this option unlikely. Thus, although the chronologic course is compatible with a direct causal link between the PPD skin test and the episode, the explanation for this phenomenon continues to be a subject of speculation. The tuberculin test may have acted as a traumatic or infectious trigger that activated the patient's innate immunity, thus increasing TNF-α production by the plasmacytoid dendritic cells and stimulating local activation and proliferation of pathogenic T cells, thereby leading to the episode. Because treatment with the same agent (or an agent of the same family)<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> could have caused the episode to persist, it was decided to change to a treatment with a different mechanism of action; the lesions were brought under control in a few days. In conclusion, our case extends the tuberculin-related complications that may be seen in patients with psoriasis who are undergoing treatment with etanercept.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0020" class="elsevierStylePara elsevierViewall">Dr. Carlos Ferrándiz and Dr. José Manuel Carrascosa have received fees as consultants and/or speakers sponsored by Wyeth, Abbot, Schering-Plough, and Janssen-Cilag.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The other authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Guinovart RM, et al. Brote de psoriasis pustulosa después de la prueba de la tuberculina en un paciente con psoriasis en plcas en tratamiento con etanercep. Actas Dermosifiliogr.2011;102:828-830.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1182 "Ancho" => 1580 "Tamanyo" => 248714 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pustules on the residual psoriasis plaques.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1185 "Ancho" => 1587 "Tamanyo" => 220914 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Episode of generalized pustular psoriasis 72<span class="elsevierStyleHsp" style=""></span>hours after performance of the tuberculin skin test.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1185 "Ancho" => 1585 "Tamanyo" => 202855 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Improvement of the lesions after 2 weeks of treatment with ciclosporin.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Psoriasis and pustular dermatitis triggered by TNF-alpha inhibitors in patients with rheumatologic conditions" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G.C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 9 | 17 |
| 2024 October | 59 | 40 | 99 |
| 2024 September | 73 | 26 | 99 |
| 2024 August | 89 | 69 | 158 |
| 2024 July | 74 | 38 | 112 |
| 2024 June | 73 | 34 | 107 |
| 2024 May | 85 | 32 | 117 |
| 2024 April | 63 | 24 | 87 |
| 2024 March | 67 | 29 | 96 |
| 2024 February | 71 | 33 | 104 |
| 2024 January | 55 | 40 | 95 |
| 2023 December | 73 | 19 | 92 |
| 2023 November | 72 | 22 | 94 |
| 2023 October | 52 | 21 | 73 |
| 2023 September | 66 | 15 | 81 |
| 2023 August | 83 | 15 | 98 |
| 2023 July | 76 | 31 | 107 |
| 2023 June | 71 | 23 | 94 |
| 2023 May | 76 | 28 | 104 |
| 2023 April | 69 | 21 | 90 |
| 2023 March | 75 | 27 | 102 |
| 2023 February | 54 | 27 | 81 |
| 2023 January | 67 | 33 | 100 |
| 2022 December | 62 | 32 | 94 |
| 2022 November | 24 | 24 | 48 |
| 2022 October | 28 | 30 | 58 |
| 2022 September | 17 | 33 | 50 |
| 2022 August | 28 | 41 | 69 |
| 2022 July | 27 | 24 | 51 |
| 2022 June | 40 | 19 | 59 |
| 2022 May | 37 | 47 | 84 |
| 2022 April | 62 | 39 | 101 |
| 2022 March | 37 | 59 | 96 |
| 2022 February | 53 | 40 | 93 |
| 2022 January | 89 | 45 | 134 |
| 2021 December | 57 | 43 | 100 |
| 2021 November | 45 | 50 | 95 |
| 2021 October | 48 | 52 | 100 |
| 2021 September | 55 | 36 | 91 |
| 2021 August | 79 | 48 | 127 |
| 2021 July | 51 | 37 | 88 |
| 2021 June | 46 | 36 | 82 |
| 2021 May | 47 | 46 | 93 |
| 2021 April | 111 | 69 | 180 |
| 2021 March | 88 | 31 | 119 |
| 2021 February | 104 | 41 | 145 |
| 2021 January | 41 | 27 | 68 |
| 2020 December | 34 | 31 | 65 |
| 2020 November | 22 | 21 | 43 |
| 2020 October | 27 | 12 | 39 |
| 2020 September | 34 | 16 | 50 |
| 2020 August | 23 | 32 | 55 |
| 2020 July | 36 | 19 | 55 |
| 2020 June | 25 | 24 | 49 |
| 2020 May | 21 | 22 | 43 |
| 2020 April | 34 | 20 | 54 |
| 2020 March | 24 | 23 | 47 |
| 2020 February | 3 | 5 | 8 |
| 2020 January | 4 | 2 | 6 |
| 2019 December | 8 | 2 | 10 |
| 2019 November | 4 | 0 | 4 |
| 2019 October | 0 | 2 | 2 |
| 2019 September | 4 | 2 | 6 |
| 2019 August | 4 | 1 | 5 |
| 2019 July | 4 | 3 | 7 |
| 2019 June | 4 | 18 | 22 |
| 2019 May | 6 | 13 | 19 |
| 2019 April | 2 | 12 | 14 |
| 2019 March | 4 | 11 | 15 |
| 2019 February | 0 | 3 | 3 |
| 2019 January | 2 | 0 | 2 |
| 2018 December | 5 | 8 | 13 |
| 2018 November | 1 | 0 | 1 |
| 2018 October | 4 | 0 | 4 |
| 2018 September | 2 | 0 | 2 |
| 2018 June | 0 | 2 | 2 |
| 2018 May | 0 | 1 | 1 |
| 2018 March | 1 | 0 | 1 |
| 2018 February | 55 | 4 | 59 |
| 2018 January | 61 | 6 | 67 |
| 2017 December | 76 | 5 | 81 |
| 2017 November | 49 | 5 | 54 |
| 2017 October | 45 | 4 | 49 |
| 2017 September | 61 | 9 | 70 |
| 2017 August | 96 | 10 | 106 |
| 2017 July | 73 | 1 | 74 |
| 2017 June | 114 | 13 | 127 |
| 2017 May | 85 | 12 | 97 |
| 2017 April | 72 | 14 | 86 |
| 2017 March | 73 | 37 | 110 |
| 2017 February | 61 | 8 | 69 |
| 2017 January | 64 | 14 | 78 |
| 2016 December | 74 | 5 | 79 |
| 2016 November | 88 | 19 | 107 |
| 2016 October | 103 | 15 | 118 |
| 2016 September | 174 | 9 | 183 |
| 2016 August | 92 | 14 | 106 |
| 2016 July | 62 | 12 | 74 |
| 2016 June | 14 | 8 | 22 |
| 2016 May | 9 | 13 | 22 |
| 2016 April | 3 | 3 | 6 |
| 2016 March | 8 | 11 | 19 |
| 2016 February | 2 | 10 | 12 |
| 2016 January | 5 | 9 | 14 |
| 2015 December | 5 | 2 | 7 |
| 2015 November | 19 | 2 | 21 |
| 2015 October | 18 | 1 | 19 |
| 2015 September | 9 | 2 | 11 |
| 2015 August | 13 | 4 | 17 |
| 2015 July | 162 | 9 | 171 |
| 2015 June | 81 | 7 | 88 |
| 2015 May | 89 | 13 | 102 |
| 2015 April | 90 | 10 | 100 |
| 2015 March | 45 | 4 | 49 |
| 2015 February | 55 | 5 | 60 |
| 2015 January | 61 | 13 | 74 |
| 2014 December | 85 | 19 | 104 |
| 2014 November | 70 | 19 | 89 |
| 2014 October | 78 | 21 | 99 |
| 2014 September | 76 | 13 | 89 |
| 2014 August | 89 | 15 | 104 |
| 2014 July | 88 | 16 | 104 |
| 2014 June | 102 | 14 | 116 |
| 2014 May | 92 | 20 | 112 |
| 2014 April | 64 | 9 | 73 |
| 2014 March | 104 | 19 | 123 |
| 2014 February | 72 | 10 | 82 |
| 2014 January | 71 | 10 | 81 |
| 2013 December | 77 | 14 | 91 |
| 2013 November | 18 | 7 | 25 |
| 2013 October | 13 | 12 | 25 |
| 2013 September | 13 | 13 | 26 |
| 2013 August | 13 | 9 | 22 |
| 2013 July | 8 | 9 | 17 |
| 2013 June | 14 | 19 | 33 |
| 2013 May | 16 | 20 | 36 |
| 2013 April | 10 | 18 | 28 |
| 2013 March | 22 | 11 | 33 |
| 2013 February | 42 | 7 | 49 |
| 2013 January | 33 | 4 | 37 |
| 2012 December | 14 | 4 | 18 |
| 2012 November | 0 | 1 | 1 |
| 2012 October | 0 | 1 | 1 |
| 2012 August | 1 | 0 | 1 |
| 2012 July | 2 | 0 | 2 |
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