The Incidence and Management of TNF-α Inhibitor Induced Paradoxical Psoriasis in Children With Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis.

Abstract

Paradoxical psoriasis is a well-described phenomenon following treatment with Tumour Necrosis Factor alpha (TNF-α) inhibitors in adult patients with Inflammatory Bowel Disease (IBD). The incidence and optimal treatment strategies are not well described in children with IBD. This subgroup of patients is disproportionately impacted by TNF-α inhibitor-induced psoriatic eruptions. Our systematic review and meta-analyses aims to describe the incidence, presentation, and management options for TNF-αinhibitor-induced psoriasis in paediatric patients with IBD. A systematic literature search was conducted using Medline, Embase and Cochrane databases for studies published up to February 2025. Retrospective cohort studies (n = 16), prospective cohort study (n = 1), and a cross-sectional study (n = 1) met inclusion criteria. Studies focusing on patients > 18 years or TNF-α inhibitors used for non-IBD conditions were excluded. A total of 3349 paediatric patients with IBD treated with TNF-α inhibitors were analysed, with 255 (7.6%) developing paradoxical psoriasis. Meta-analysis of 13 studies meeting sample size criteria yielded a pooled incidence of 6.8% (95% CI: 0.04-0.10). Infliximab (IFX) accounted for 151 (79.1%) of cases, whereas adalimumab (ADA) contributed to 40 (20.9%) cases. The median time to clinical eruption was 15.0 months (12.0-18.0). Among affected patients, 22.3% (51/229) discontinued their prescribed TNF-α inhibitor and 5.7% (13/229) were subsequently switched to an alternative TNF-α inhibitor. Ustekinumab (UST) was the most common non-TNF-α alternative (14/94). TNF-α inhibitor-induced psoriasis is a common adverse effect in paediatric IBD, with a significant proportion of cases necessitating treatment discontinuation. Long-term outcomes following a switch to non-TNF-α biologics remain unclear, highlighting the need for further prospective studies.