Paradoxical psoriasis induced by adalimumab in a patient with Crohn’s disease and sacroiliitis: A case report

Abstract

Background

Crohn’s disease (CD), a chronic inflammatory bowel disease, has various clinical manifestations that can be treated and controlled with tumor necrosis factor-alpha (TNF-α) inhibitors, like adalimumab, as therapy of choice. Despite the number of patients that have benefited from this treatment and achieved remission of their symptoms, some experience paradoxically induced psoriatic skin lesions, a condition known as paradoxical psoriasis.

Case Presentation

We present the case of a 46-year-old Lebanese woman known to have Crohn’s disease, with a history of recurrent flares and episodes of sacroiliitis not controlled on azathioprine. Hence, we switched the patient onto adalimumab, whereby she experienced full remission of her disease associated symptoms for around a duration of five months until she developed widespread erythematous, scaly silver plaques which were determined by dermatologic assessment and biopsy to be psoriasiform dermatitis. The offending agent, adalimumab was discontinued and replaced with ustekinumab, an interleukin-12/23 inhibitor, that led to the complete disappearance of the skin lesions and subsidence of her Crohn’s related gastrointestinal and musculoskeletal symptoms.

Conclusion

When starting a patient on a TNF-α inhibitor therapy, physicians should pay close attention and participate in educating patients about possible cutaneous reactions that may occur during treatment. Early detection of these psoriasiform lesions is imperative for prompt treatment adjustments, such as switching to agents with different immunological targets, to prevent widespread of the rash and improve patient outcomes.