Paradoxical Psoriasiform Skin Eruption in Pediatric Patients with Inflammatory Bowel Disease Treated with TNFα Inhibitors

Background: Tumor necrosis factor α inhibitors (TNFαI)-induced psoriasiform eruptions are a well-known phenomenon among adults. However, data are limited regarding this reaction in children.

Objectives: To describe in pediatric patients with inflammatory bowel diseases (IBD), the clinical characteristics of TNFαI-induced psoriasiform eruptions and the outcomes of various therapeutic options.

Methods: We reviewed the medical charts of pediatric patients (aged <18 years old) with IBD who developed TNFαI-induced psoriasiform eruptions during 2006-2022.

Results: Among 454 patients with IBD treated with TNFαI, 58 (12.8%) were diagnosed with TNFαI-induced psoriasiform eruptions, of whom 51 were included in the study. The female to male ratio was 1:1.3. The median age at skin eruption was 14.1 [interquartile range, 12.11-16.05] years. The median elapsed time to eruption appearance was 15 [interquartile range, 7-24] months after initiation of the treatment. All the patients were treated with topical steroids and 17 (33%) needed systemic treatment (phototherapy, methotrexate or acitretin). Sixteen patients (31%) needed to stop TNFαI treatment due to an intractable eruption. Female patients, patients with inflammatory alopecia and patients who were treated with methotrexate or phototherapy were more prone to stop TNFαI.

Conclusions: TNFαI-induced psoriasiform eruptions are common in pediatric patients with IBD. The eruption may appear months or even years after treatment initiation. Almost one-third of the described patients had to replace their treatment due to a recalcitrant cutaneous eruption. This indicates that a multidisciplinary approach is required for effective management.