Abstract

Background : Tumor necrosis factor-alpha inhibitors (anti-TNF-α) have revolutionized the management of chronic autoimmune diseases, including inflammatory bowel disease, rheumatoid arthritis, psoriasis, and psoriatic arthritis. Despite their efficacy, these agents have paradoxically been associated with the induction or exacerbation of psoriatic lesions, a phenomenon increasingly reported in the literature.

Objective : This study aimed to describe the epidemiological and clinical characteristics of paradoxical psoriasis induced by anti-TNF-α therapy, analyze the therapeutic approaches employed, and assess patient outcomes.

Methods : We conducted a retrospective analysis of 10 cases of paradoxical psoriasis reported to the National Center of Pharmacovigilance, Chalbi Belkahia (Tunis, Tunisia), between June 2018 and June 2023. Cases were selected from a database connected with VigiBase® and analyzed using the French method of imputability. Only cases where anti-TNF-α agents were strongly suspected of inducing or exacerbating psoriasis were included.

Results : The study included 10 patients (7 women, 3 men) with a mean age of 42.8 years. Eight patients had no prior history of psoriasis before starting anti-TNF-α therapy. Psoriatic lesions appeared after an average of 25.6 months (range: 2 months-6 years) following treatment initiation. Clinical presentations included plaque psoriasis (4 patients) and pustular psoriasis (4 patients), while guttate and inverse forms were less frequent. The most frequently affected underlying conditions were ankylosing spondylitis (n=3), rheumatoid arthritis (n=3), psoriatic arthritis (n=2), and Crohn’s disease (n=2). Management strategies varied: anti-TNF-α therapy was discontinued in 8 patients, leading to remission in 7. Four patients were switched to another anti-TNF-α agent, and none experienced recurrence.

Conclusion : Paradoxical psoriasis represents a significant adverse effect of anti-TNF-α therapy, with variable clinical presentations and management outcomes. Although switching to a different anti-TNF-α agent may be a viable option, careful monitoring and individualized treatment strategies are essential for optimal outcomes. Further studies are needed to clarify underlying mechanisms and identify potential risk factors for this paradoxical reaction.