Case and research letter
Flexural or Inverse Psoriasis in a Patient With Hidradenitis Suppurativa Receiving Treatment With Infliximab
Aparición de psoriasis flexural o invertida en una paciente con hidrosadenitis supurativa en tratamiento con infliximab
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Nuño-González, L. Dehesa, C. Ricotti, F. Kerdel" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Nuño-González" "email" => array:1 [ 0 => "almudenanuno@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "L." "apellidos" => "Dehesa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Ricotti" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "F." "apellidos" => "Kerdel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Dermatología, Hospital Universitario Fundación Alcorcón, Madrid, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Florida Academic Dermatology Center, University of Miami Hospital, Florida, USA" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Aparición de psoriasis flexural o invertida en una paciente con hidrosadenitis supurativa en tratamiento con infliximab" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1265 "Ancho" => 1583 "Tamanyo" => 408605 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Epidermis with regular acanthosis, parakeratosis and moderate hypogranulosis. Hematoxylin-eosin, original magnification ×40.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease that is found predominantly in the flexures. The regions with a high density of apocrine glands (axillas, groin, buttocks, inframammary region, and perianal region) are those most often affected and the disease has a marked impact on the quality of life of patients. Though many therapeutic options are available, the response is inadequate in most cases and patients can present many years of recurrent outbreaks that have major physical and psychological sequelae.</p><p id="par0010" class="elsevierStylePara elsevierViewall">For some years anti-tumor necrosis factor α (anti-TNF-α) agents have been a treatment option for patients with severe HS who do not respond to conventional therapy.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> Although there have been reports of cases of paradoxical psoriasis with anti-TNF-α agents,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–8</span></a> to our knowledge this disease has not yet been described in patients with HS treated with these drugs.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We report the case of a 50-year-old, obese, non-smoking woman with no relevant past history except for HS diagnosed at the age of 20 and that had worsened over the previous 3 years. She had received several treatments: daily antiseptic washes, topical clindamycin and mupirocin, several 6-month courses of minocycline 100<span class="elsevierStyleHsp" style=""></span>mg per day, and a 3-month course of daily clindamycin 300<span class="elsevierStyleHsp" style=""></span>mg plus rifampicin 300 <span class="elsevierStyleHsp" style=""></span>mg. The response to all these treatments had been poor, so the patient was included in a clinical trial for treatment of HS with infliximab<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and began treatment at a dose of 5<span class="elsevierStyleHsp" style=""></span>mg/kg every 8 weeks. The HS improved with the first infusion of the drug, but after 10 months of treatment the patient developed well-defined, scaly, erythematous lesions in the groin, axillas, and intergluteal and inframammary regions (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Direct microscopy with potassium hydroxide and culture were negative for fungi. Histology showed an epidermis with regular acanthosis, hyperkeratosis with parakeratosis, and suprapapillary thinning, confirming the diagnosis of flexural or inverted psoriasis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). At the time of writing, the patient was receiving intermittent treatment with topical hydrocortisone 2.5%, which enabled her to keep the psoriasis under control. She continued the treatment with infliximab and the clinical course of the HS was favourable.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The therapeutic management of HS is a challenge for the dermatologist. Several treatments have shown mixed results and none of them has been fully effective. Local treatments include antiseptic washes, topical antibiotics, and intralesional corticosteroid injections. Systemic treatments include oral retinoids, antibiotics such as minocycline or combined clindamycin and rifampicin, contraceptives alone or in combination with an antiandrogen, cycles of oral corticosteroids, and sulfone. Surgery, laser hair removal, photodynamic therapy, and even radiation therapy have also shown some efficacy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Recently, anti-TNF-α agents have shown good results in moderate to severe HS that is poorly controlled by conventional treatments.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> These drugs are used for inflammatory diseases in which TNF-α is involved, such as inflammatory bowel disease, rheumatoid arthritis, ankylosing spondylitis, and psoriasis. Inflammatory bowel disease has been associated with an increased risk of developing HS.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Moreover, the risk of developing psoriasis is of 6% to 11% in patients with inflammatory bowel disease, a higher risk than in the general population.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> Smoking, treatment with lithium salts, and obesity are aggravating factors for both HS and psoriasis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,9</span></a> In addition, TNF-α has been implicated in the pathophysiology of both diseases. Elevated levels of TNF-α, IL-10, and IL-1β have recently been reported in patients with HS, which would explain the good response to these drugs<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>; however, not all patients with HS respond to anti-TNF-α agents and most do so only partially.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a> Furthermore, HS lesions are often superinfected by microorganisms and there is a theoretical risk of dissemination of the infection with anti-TNF-α agents.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Though anti-TNF-α agents are indicated for the treatment of moderate and severe forms of psoriasis, the possibility of paradoxical phenomena, such as the onset or exacerbation of psoriasis, is recognized with all of them (infliximab, etanercept, and adalimumab).<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–8</span></a> Outbreaks of psoriasis associated with this drug usually appear as palmoplantar, pustular, or plaque-type psoriasis and more rarely as inverse psoriasis, as in our patient.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The time of onset varies from 4 months to several years after the start of treatment.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> Depending on the severity of the psoriasis symptoms, the anti-TNF-α agent can be maintained or replaced by another immunosuppressant. In 85% of cases, the change to another anti-TNF-α agent does not solve the occurrence of psoriasis, which is therefore considered a class effect.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The mechanism by which psoriasis occurs in patients treated with anti-TNF-α agents is unknown. It has been suggested that the decreased TNF-α causes an increase in interferon α, which in some patients leads to the development and worsening of psoriasis lesions, but further studies are needed to confirm this hypothesis.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,10</span></a> By contrast, interferon α levels are decreased in HS.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> This finding would explain the good response of HS to treatment with infliximab and the onset of psoriasis in our patient.</p><p id="par0035" class="elsevierStylePara elsevierViewall">We stress the importance of this case because it is the first published case of the appearance of psoriasis in a patient with HS treated with an anti-TNF-α agent (infliximab), because it had an atypical presentation as flexural or inverse psoriasis, and because it showed a good response to treatment with only topical corticosteroids, without the need to interrupt the infliximab prescribed to treat the underlying disease.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">Drs. Almudena González and Carlos Nuño-Ricotti declare that they have no conflicts of interest.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Dr. Luis Dehesa has participated in conferences for Abbott, Pfizer, and Astellas.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Dr. Francisco Kerdel has participated in conferences and studies for Amgen, Abbott, Jansen, Schering-Plough, Pfizer, and Eisai.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interests" ] 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: Nuño-González A, et al. Aparición de psoriasis flexural o invertida en una paciente con hidrosadenitis supurativa en tratamiento con infliximab. Actas Dermosifiliogr. 2012;103:936–7.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1078 "Ancho" => 2333 "Tamanyo" => 196151 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Inverse psoriasis lesions in our patient with hidradenitis suppurativa: A, in the groin and B, in the gluteal cleft.</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" => 1265 "Ancho" => 1583 "Tamanyo" => 408605 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Epidermis with regular acanthosis, parakeratosis and moderate hypogranulosis. Hematoxylin-eosin, original magnification ×40.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Manejo práctico de la hidrosadenitis supurativa" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Pedraz" 1 => "E. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 9 | 19 | 28 |
| 2024 Octubre | 81 | 46 | 127 |
| 2024 Septiembre | 106 | 29 | 135 |
| 2024 Agosto | 117 | 66 | 183 |
| 2024 Julio | 103 | 41 | 144 |
| 2024 Junio | 114 | 51 | 165 |
| 2024 Mayo | 88 | 45 | 133 |
| 2024 Abril | 92 | 37 | 129 |
| 2024 Marzo | 94 | 39 | 133 |
| 2024 Febrero | 104 | 41 | 145 |
| 2024 Enero | 100 | 37 | 137 |
| 2023 Diciembre | 79 | 29 | 108 |
| 2023 Noviembre | 89 | 33 | 122 |
| 2023 Octubre | 86 | 44 | 130 |
| 2023 Septiembre | 82 | 25 | 107 |
| 2023 Agosto | 81 | 18 | 99 |
| 2023 Julio | 89 | 49 | 138 |
| 2023 Junio | 91 | 31 | 122 |
| 2023 Mayo | 108 | 41 | 149 |
| 2023 Abril | 92 | 33 | 125 |
| 2023 Marzo | 83 | 40 | 123 |
| 2023 Febrero | 67 | 37 | 104 |
| 2023 Enero | 66 | 39 | 105 |
| 2022 Diciembre | 84 | 52 | 136 |
| 2022 Noviembre | 63 | 32 | 95 |
| 2022 Octubre | 34 | 42 | 76 |
| 2022 Septiembre | 32 | 34 | 66 |
| 2022 Agosto | 26 | 50 | 76 |
| 2022 Julio | 27 | 32 | 59 |
| 2022 Junio | 36 | 29 | 65 |
| 2022 Mayo | 60 | 43 | 103 |
| 2022 Abril | 96 | 41 | 137 |
| 2022 Marzo | 119 | 68 | 187 |
| 2022 Febrero | 121 | 45 | 166 |
| 2022 Enero | 87 | 43 | 130 |
| 2021 Diciembre | 67 | 62 | 129 |
| 2021 Noviembre | 84 | 69 | 153 |
| 2021 Octubre | 91 | 68 | 159 |
| 2021 Septiembre | 70 | 43 | 113 |
| 2021 Agosto | 67 | 42 | 109 |
| 2021 Julio | 60 | 61 | 121 |
| 2021 Junio | 68 | 48 | 116 |
| 2021 Mayo | 59 | 37 | 96 |
| 2021 Abril | 93 | 71 | 164 |
| 2021 Marzo | 120 | 49 | 169 |
| 2021 Febrero | 74 | 38 | 112 |
| 2021 Enero | 59 | 37 | 96 |
| 2020 Diciembre | 65 | 36 | 101 |
| 2020 Noviembre | 51 | 34 | 85 |
| 2020 Octubre | 60 | 23 | 83 |
| 2020 Septiembre | 71 | 24 | 95 |
| 2020 Agosto | 61 | 26 | 87 |
| 2020 Julio | 49 | 18 | 67 |
| 2020 Junio | 30 | 34 | 64 |
| 2020 Mayo | 28 | 14 | 42 |
| 2020 Abril | 26 | 23 | 49 |
| 2020 Marzo | 38 | 39 | 77 |
| 2020 Febrero | 7 | 7 | 14 |
| 2020 Enero | 2 | 8 | 10 |
| 2019 Diciembre | 4 | 7 | 11 |
| 2019 Noviembre | 4 | 8 | 12 |
| 2019 Octubre | 0 | 4 | 4 |
| 2019 Septiembre | 4 | 6 | 10 |
| 2019 Agosto | 4 | 8 | 12 |
| 2019 Julio | 4 | 28 | 32 |
| 2019 Junio | 4 | 50 | 54 |
| 2019 Mayo | 5 | 137 | 142 |
| 2019 Abril | 2 | 73 | 75 |
| 2019 Marzo | 0 | 23 | 23 |
| 2019 Febrero | 2 | 22 | 24 |
| 2019 Enero | 0 | 13 | 13 |
| 2018 Diciembre | 2 | 19 | 21 |
| 2018 Noviembre | 2 | 2 | 4 |
| 2018 Octubre | 1 | 0 | 1 |
| 2018 Septiembre | 4 | 8 | 12 |
| 2018 Agosto | 0 | 17 | 17 |
| 2018 Julio | 0 | 15 | 15 |
| 2018 Junio | 0 | 15 | 15 |
| 2018 Mayo | 0 | 11 | 11 |
| 2018 Abril | 0 | 5 | 5 |
| 2018 Marzo | 1 | 13 | 14 |
| 2018 Febrero | 63 | 16 | 79 |
| 2018 Enero | 70 | 13 | 83 |
| 2017 Diciembre | 70 | 12 | 82 |
| 2017 Noviembre | 52 | 9 | 61 |
| 2017 Octubre | 36 | 5 | 41 |
| 2017 Septiembre | 52 | 15 | 67 |
| 2017 Agosto | 91 | 25 | 116 |
| 2017 Julio | 89 | 25 | 114 |
| 2017 Junio | 97 | 47 | 144 |
| 2017 Mayo | 94 | 14 | 108 |
| 2017 Abril | 91 | 20 | 111 |
| 2017 Marzo | 61 | 13 | 74 |
| 2017 Febrero | 35 | 12 | 47 |
| 2017 Enero | 34 | 19 | 53 |
| 2016 Diciembre | 77 | 11 | 88 |
| 2016 Noviembre | 101 | 21 | 122 |
| 2016 Octubre | 104 | 15 | 119 |
| 2016 Septiembre | 124 | 34 | 158 |
| 2016 Agosto | 100 | 17 | 117 |
| 2016 Julio | 65 | 8 | 73 |
| 2016 Junio | 18 | 19 | 37 |
| 2016 Mayo | 16 | 8 | 24 |
| 2016 Abril | 15 | 4 | 19 |
| 2016 Marzo | 17 | 3 | 20 |
| 2016 Febrero | 11 | 3 | 14 |
| 2016 Enero | 11 | 1 | 12 |
| 2015 Diciembre | 11 | 2 | 13 |
| 2015 Noviembre | 13 | 2 | 15 |
| 2015 Octubre | 17 | 12 | 29 |
| 2015 Septiembre | 22 | 1 | 23 |
| 2015 Agosto | 21 | 3 | 24 |
| 2015 Julio | 140 | 12 | 152 |
| 2015 Junio | 90 | 10 | 100 |
| 2015 Mayo | 125 | 26 | 151 |
| 2015 Abril | 127 | 26 | 153 |
| 2015 Marzo | 744 | 18 | 762 |
| 2015 Febrero | 486 | 17 | 503 |
| 2015 Enero | 63 | 16 | 79 |
| 2014 Diciembre | 71 | 30 | 101 |
| 2014 Noviembre | 50 | 5 | 55 |
| 2014 Octubre | 67 | 13 | 80 |
| 2014 Septiembre | 55 | 6 | 61 |
| 2014 Agosto | 106 | 12 | 118 |
| 2014 Julio | 93 | 4 | 97 |
| 2014 Junio | 91 | 8 | 99 |
| 2014 Mayo | 54 | 8 | 62 |
| 2014 Abril | 27 | 6 | 33 |
| 2014 Marzo | 15 | 15 | 30 |
| 2014 Febrero | 19 | 8 | 27 |
| 2014 Enero | 9 | 9 | 18 |
| 2013 Diciembre | 20 | 10 | 30 |
| 2013 Noviembre | 14 | 12 | 26 |
| 2013 Octubre | 19 | 13 | 32 |
| 2013 Septiembre | 12 | 10 | 22 |
| 2013 Agosto | 14 | 19 | 33 |
| 2013 Julio | 10 | 21 | 31 |
| 2013 Junio | 16 | 15 | 31 |
| 2013 Mayo | 16 | 14 | 30 |
| 2013 Abril | 18 | 17 | 35 |
| 2013 Marzo | 19 | 18 | 37 |
| 2013 Febrero | 48 | 11 | 59 |
| 2013 Enero | 154 | 11 | 165 |
| 2012 Diciembre | 80 | 10 | 90 |
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