Filipa Osório

Anti-TNF-alpha induced psoriasiform eruptions with severe scalp involvement and alopecia: report of five cases and review of the literature.

We describe 5 cases of anti-tumor necrosis factor-alpha (anti-TNF-α) induced psoriasiform eruptions with severe scalp involvement inducing inflammatory alopecia and review the literature on this subject. All our 5 patients were provided topical therapy, with good results in only 1 case. The remaining 4 were provided systemic therapy (methotrexate ± cyclosporine): 3 concomitantly suspended the anti-TNF-α treatment (2 are currently clear/almost clear but 1 has so far only observed mild improvement) and 1 switched anti-TNF-α (recurrent flare-ups of the disease continue). So far, no patient has developed scarring alopecia. To our knowledge, a total of 15 cases of anti-TNF-α induced psoriatic alopecia have been described. Anti-TNF-α was discontinued in 9 of the 15 patients and systemic therapy was provided to 9 of the 15 patients. Nonetheless, 2 patients developed scarring alopecia. We conclude that in anti-TNF-α induced psoriasiform eruptions some patients may respond to topical treatment, however in cases of severe scalp involvement anti-TNF-α suspension and systemic treatment should be considered in order to avoid scarring alopecia.

Infliximab in Psoriasis and Psoriatic Arthritis

Psoriasis is a chronic inflammatory disorder of the skin and joints. Although rarely life threatening, psoriasis can significantly impair quality of life (QOL) and cause considerable physical and psychological distress. Between 6 and 42% of patients with psoriasis develop psoriatic arthritis, which is characterized by stiffness, pain, swelling and tenderness of the joints. Nail psoriasis is highly prevalent in both plaque-type psoriasis and psoriatic arthritis and is found in approximately 50% of patients with psoriasis and in 80% of patients with psoriatic arthritis. Infliximab, a chimeric human-murine monoclonal antibody directed against tumour necrosis factor α, is approved in the USA and EU for the treatment of plaque psoriasis and psoriatic arthritis at a recommended dosage of 5 mg/kg administered by intravenous infusion at 0,2 and 6 weeks, then every 8 weeks thereafter. The EXPRESS and EXPRESS II trials demonstrated that infliximab is efficacious as induction and maintenance therapy in the treatment of moderate to severe plaque psoriasis and also improved health-related QOL. Infliximab is also efficacious in the treatment of psoriatic arthritis, as shown in the IMPACT and IMPACT II studies. Infliximab is generally well tolerated, with a similar adverse event profile in both psoriasis and psoriatic arthritis. The use of infliximab in three case reports is presented. The patients are similar to those normally seen by clinicians, and include a male patient with plaque psoriasis and a history of severe psoriatic arthritis who was corticosteroid dependent and in whom other systemic treatments were not effective or were not able to be used. This patient showed a rapid response to infliximab with no skin lesions or arthritis after 7 weeks’ treatment. Infliximab was also safe and effective in the treatment of a female patient with plaque and nail psoriasis and a history of psoriatic arthritis. Importantly, this case report supports the efficacy of infliximab in psoriatic nail disease in the context of severe skin and joint involvement. Case 3 describes a young male patient with moderate plaque-type psoriasis associated with severe nail involvement and early signs of psoriatic arthritis. Treatment with infliximab improved nail psoriasis and appears to be an effective biological treatment for nail psoriasis. Importantly, ultrasound was able to diagnose joint involvement, as seen from the proliferative synovitis in the distal interphalangeal joint and mild enthesitis, despite there being no clinical evidence of psoriatic arthritis. This case report highlights the importance of early screening. If such abnormalities are detected early on in the course of psoriasis, clinicians may be able to predict which patients are more likely to develop psoriatic arthritis, and therefore offer effective and long-term treatment that may reduce the disability and impairment of daily activities that can be associated with psoriatic arthritis.

Cat‐scratch disease during anti‐tumor necrosis factor‐alpha therapy: case report and review of the literature

References 1 Nagore E, Insa A, Sanmartín O. Antineoplastic therapy-induced palmar plantar erythrodysesthesia (hand-foot) syndrome. Incidence, recognition and management. Am J Clin Dermatol 2000; 1: 225–234. 2 Chew L, Chuen VS. Cutaneous reaction associated with weekly docetaxel administration. J Oncol Pharm Pract 2009; 15: 29–34. 3 Eisenhauer EA, Vermorken JB. The taxoids. Comparative clinical pharmacology and therapeutic potential. Drugs 1998; 55: 5–30. 4 Benghiat H, Al-Niaimi A. Palmar-plantar erythrodysesthesia secondary to docetaxel chemotherapy: a case report. J Med Case Reports 2011; 5: 80. 5 Webster-Gandy JD, How C, Harrold K. Palmar-plantar erythrodysesthesia (PPE): a literature review with commentary on experience in a cancer centre. Eur J Oncol Nurs 2007; 11: 238–246. 6 Eich D, Scharffetter-Kochanek K, Eich HT, et al. Acral erythrodysesthesia syndrome caused by intravenous infusion of docetaxel in breast cancer. Am J Clin Oncol 2002; 25: 599–602. 7 Zimmerman GC, Keeling JH, Lowry M, et al. Prevention of docetaxel-induced erythrodysesthesia with local hypothermia. J Natl Cancer Inst 1994; 86: 557–558. 8 Kara IO, Sahin B, Erkisi M. Palmar-plantar erythrodysesthesia due to docetaxel-capecitabine therapy is treated with vitamin E without dose reduction. Breast 2006; 15: 414–424. 9 Corazza M, Minghetti S, Zauli S, et al. Pegylated liposomal doxorubicin-induced palmar-plantar erythrodysestesia in multiple uncommon sites. Eur J Dermatol 2011; 21: 433–434. 10 Chu CY, Yang CH, Yang CY, et al. Fixed erythrodysaesthesia plaque due to intravenous injection of docetaxel. Br J Dermatol 2000; 142: 808–811. 11 Cruz A, Temu T, Hines-Telang G, Kroumpouzos G. Paclitaxel-induced neutrophilic adverse reaction and acral erythema. Acta Derm Venereol 2011; 91: 86–87.

Cutaneous Morbidity Among Inflammatory Bowel Disease Patients: A Cohort Study

Background and Aims Patients with inflammatory bowel diseases are prone to cutaneous manifestations. The aim of this study was to investigate their prevalence, type and association to demographic and clinical factors. Methods This was a cross-sectional study. Information relative to patients of a central Portuguese hospital with a definitive diagnosis of an inflammatory bowel disease, who were prospectively recruited, was collected. Results The final cohort included 342 patients, 62% of whom had Crohns disease and 38% had ulcerative colitis. Cutaneous extraintestinal manifestations were present in 44.4% of all patients; this prevalence was lower [14.9%] when excluding cutaneous manifestations secondary to nutrition deficiency or drugs. These skin lesions were classified as granulomatous [0.3%], reactive [4.4%], immunologically associated [10.5%] and secondary to nutritional deficiencies [6.4%] or to bowel-related therapy [29.5%]. Excluding those secondary to nutrition or drugs, cutaneous manifestations were significantly associated with females (odds ratio [OR] 3.210 [1.625-6.340], p = 0.001) and younger patients (OR 0.954 [0.924-0.985], p = 0.004). Additionally, their occurrence was related to patients up to 16 years (OR 13.875 [1.332-144.484], p = 0.028) among the Crohns disease sub-cohort, whereas in the ulcerative colitis sub-cohort they were more likely to occur in patients with extensive colitis (OR 5.317 [1.552-18.214], p = 0.008). Conclusions Nearly half of the patients analysed had at least one cutaneous extraintestinal manifestation. The fact that certain lesions tend to be more common among patients with defined characteristics should alert the physicians and allow an early diagnosis and, when pertinent, a reference to dermatology.

P347 Severe scalp and skin involvement in Crohn's disease patients under treatment with anti-tumor necrosis factor alpha

P346 Short term dose tailoring of anti TNF-a therapy delivers useful clinical efficacy in Crohn’s disease patients with secondary loss of response S. Ghaly1 *, S. Costello2, L. Beswick3, A. Pudipeddi4, A. Agarwal2, A. Sechi5, B. Headon3, R. Prosser6, S. Connor5, I.C. Lawrance7, M. Sparrow3, P. Bampton6, A. Walsh4, J. Andrews2. 1St. Vincent’s Hospital, University of New South Wales, Department of Gastroenterology, Sydney, Australia, 2Royal Adelaide Hospital, Department of Gastroenterology, Adelaide, Australia, 3The Alfred Hospital, Department of Gastroenterology, Melbourne, Australia, 4St. Vincent’s Hospital, Department of Gastroenterology, Sydney, Australia, 5Liverpool Hospital, Department of Gastroenterology, Sydney, Australia, 6Flinders Medical Centre, Department of Gastroenterology, Adelaide, Australia, 7Fremantle Hospital, Centre for Inflammatory Bowel Disease, Fremantle, Australia