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
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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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 9 | 9 | 18 |
| 2024 Octubre | 59 | 40 | 99 |
| 2024 Septiembre | 73 | 26 | 99 |
| 2024 Agosto | 89 | 69 | 158 |
| 2024 Julio | 74 | 38 | 112 |
| 2024 Junio | 73 | 34 | 107 |
| 2024 Mayo | 85 | 32 | 117 |
| 2024 Abril | 63 | 24 | 87 |
| 2024 Marzo | 67 | 29 | 96 |
| 2024 Febrero | 71 | 33 | 104 |
| 2024 Enero | 55 | 40 | 95 |
| 2023 Diciembre | 73 | 19 | 92 |
| 2023 Noviembre | 72 | 22 | 94 |
| 2023 Octubre | 52 | 21 | 73 |
| 2023 Septiembre | 66 | 15 | 81 |
| 2023 Agosto | 83 | 15 | 98 |
| 2023 Julio | 76 | 31 | 107 |
| 2023 Junio | 71 | 23 | 94 |
| 2023 Mayo | 76 | 28 | 104 |
| 2023 Abril | 69 | 21 | 90 |
| 2023 Marzo | 75 | 27 | 102 |
| 2023 Febrero | 54 | 27 | 81 |
| 2023 Enero | 67 | 33 | 100 |
| 2022 Diciembre | 62 | 32 | 94 |
| 2022 Noviembre | 24 | 24 | 48 |
| 2022 Octubre | 28 | 30 | 58 |
| 2022 Septiembre | 17 | 33 | 50 |
| 2022 Agosto | 28 | 41 | 69 |
| 2022 Julio | 27 | 24 | 51 |
| 2022 Junio | 40 | 19 | 59 |
| 2022 Mayo | 37 | 47 | 84 |
| 2022 Abril | 62 | 39 | 101 |
| 2022 Marzo | 37 | 59 | 96 |
| 2022 Febrero | 53 | 40 | 93 |
| 2022 Enero | 89 | 45 | 134 |
| 2021 Diciembre | 57 | 43 | 100 |
| 2021 Noviembre | 45 | 50 | 95 |
| 2021 Octubre | 48 | 52 | 100 |
| 2021 Septiembre | 55 | 36 | 91 |
| 2021 Agosto | 79 | 48 | 127 |
| 2021 Julio | 51 | 37 | 88 |
| 2021 Junio | 46 | 36 | 82 |
| 2021 Mayo | 47 | 46 | 93 |
| 2021 Abril | 111 | 69 | 180 |
| 2021 Marzo | 88 | 31 | 119 |
| 2021 Febrero | 104 | 41 | 145 |
| 2021 Enero | 41 | 27 | 68 |
| 2020 Diciembre | 34 | 31 | 65 |
| 2020 Noviembre | 22 | 21 | 43 |
| 2020 Octubre | 27 | 12 | 39 |
| 2020 Septiembre | 34 | 16 | 50 |
| 2020 Agosto | 23 | 32 | 55 |
| 2020 Julio | 36 | 19 | 55 |
| 2020 Junio | 25 | 24 | 49 |
| 2020 Mayo | 21 | 22 | 43 |
| 2020 Abril | 34 | 20 | 54 |
| 2020 Marzo | 24 | 23 | 47 |
| 2020 Febrero | 3 | 5 | 8 |
| 2020 Enero | 4 | 2 | 6 |
| 2019 Diciembre | 8 | 2 | 10 |
| 2019 Noviembre | 4 | 0 | 4 |
| 2019 Octubre | 0 | 2 | 2 |
| 2019 Septiembre | 4 | 2 | 6 |
| 2019 Agosto | 4 | 1 | 5 |
| 2019 Julio | 4 | 3 | 7 |
| 2019 Junio | 4 | 18 | 22 |
| 2019 Mayo | 6 | 13 | 19 |
| 2019 Abril | 2 | 12 | 14 |
| 2019 Marzo | 4 | 11 | 15 |
| 2019 Febrero | 0 | 3 | 3 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Diciembre | 5 | 8 | 13 |
| 2018 Noviembre | 1 | 0 | 1 |
| 2018 Octubre | 4 | 0 | 4 |
| 2018 Septiembre | 2 | 0 | 2 |
| 2018 Junio | 0 | 2 | 2 |
| 2018 Mayo | 0 | 1 | 1 |
| 2018 Marzo | 1 | 0 | 1 |
| 2018 Febrero | 55 | 4 | 59 |
| 2018 Enero | 61 | 6 | 67 |
| 2017 Diciembre | 76 | 5 | 81 |
| 2017 Noviembre | 49 | 5 | 54 |
| 2017 Octubre | 45 | 4 | 49 |
| 2017 Septiembre | 61 | 9 | 70 |
| 2017 Agosto | 96 | 10 | 106 |
| 2017 Julio | 73 | 1 | 74 |
| 2017 Junio | 114 | 13 | 127 |
| 2017 Mayo | 85 | 12 | 97 |
| 2017 Abril | 72 | 14 | 86 |
| 2017 Marzo | 73 | 37 | 110 |
| 2017 Febrero | 61 | 8 | 69 |
| 2017 Enero | 64 | 14 | 78 |
| 2016 Diciembre | 74 | 5 | 79 |
| 2016 Noviembre | 88 | 19 | 107 |
| 2016 Octubre | 103 | 15 | 118 |
| 2016 Septiembre | 174 | 9 | 183 |
| 2016 Agosto | 92 | 14 | 106 |
| 2016 Julio | 62 | 12 | 74 |
| 2016 Junio | 14 | 8 | 22 |
| 2016 Mayo | 9 | 13 | 22 |
| 2016 Abril | 3 | 3 | 6 |
| 2016 Marzo | 8 | 11 | 19 |
| 2016 Febrero | 2 | 10 | 12 |
| 2016 Enero | 5 | 9 | 14 |
| 2015 Diciembre | 5 | 2 | 7 |
| 2015 Noviembre | 19 | 2 | 21 |
| 2015 Octubre | 18 | 1 | 19 |
| 2015 Septiembre | 9 | 2 | 11 |
| 2015 Agosto | 13 | 4 | 17 |
| 2015 Julio | 162 | 9 | 171 |
| 2015 Junio | 81 | 7 | 88 |
| 2015 Mayo | 89 | 13 | 102 |
| 2015 Abril | 90 | 10 | 100 |
| 2015 Marzo | 45 | 4 | 49 |
| 2015 Febrero | 55 | 5 | 60 |
| 2015 Enero | 61 | 13 | 74 |
| 2014 Diciembre | 85 | 19 | 104 |
| 2014 Noviembre | 70 | 19 | 89 |
| 2014 Octubre | 78 | 21 | 99 |
| 2014 Septiembre | 76 | 13 | 89 |
| 2014 Agosto | 89 | 15 | 104 |
| 2014 Julio | 88 | 16 | 104 |
| 2014 Junio | 102 | 14 | 116 |
| 2014 Mayo | 92 | 20 | 112 |
| 2014 Abril | 64 | 9 | 73 |
| 2014 Marzo | 104 | 19 | 123 |
| 2014 Febrero | 72 | 10 | 82 |
| 2014 Enero | 71 | 10 | 81 |
| 2013 Diciembre | 77 | 14 | 91 |
| 2013 Noviembre | 18 | 7 | 25 |
| 2013 Octubre | 13 | 12 | 25 |
| 2013 Septiembre | 13 | 13 | 26 |
| 2013 Agosto | 13 | 9 | 22 |
| 2013 Julio | 8 | 9 | 17 |
| 2013 Junio | 14 | 19 | 33 |
| 2013 Mayo | 16 | 20 | 36 |
| 2013 Abril | 10 | 18 | 28 |
| 2013 Marzo | 22 | 11 | 33 |
| 2013 Febrero | 42 | 7 | 49 |
| 2013 Enero | 33 | 4 | 37 |
| 2012 Diciembre | 14 | 4 | 18 |
| 2012 Noviembre | 0 | 1 | 1 |
| 2012 Octubre | 0 | 1 | 1 |
| 2012 Agosto | 1 | 0 | 1 |
| 2012 Julio | 2 | 0 | 2 |
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