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Adverse cutaneous reactions to targeted biologic therapies
Other Resources UpToDate PubMed

Adverse cutaneous reactions to targeted biologic therapies

Contributors: Vivian Wong MD, PhD, Susan Burgin MD
Other Resources UpToDate PubMed


Antibody-based "biologic" therapies are widely used in dermatology for various indications, including psoriasis, atopic dermatitis, and other inflammatory conditions. During treatment with these agents, a variety of unique, paradoxical cutaneous reactions may occur. Worsening of a preexisting immune-mediated disorder (eg, psoriasis) has also been reported. Overlapping reactions may also occur. Onset may be shortly after initiation of treatment, or several months afterwards. Tumor necrosis factor alpha (TNF-α) inhibitors carry the highest risk of paradoxical reactions.

The following reactions have been reported:

TNF-α inhibitors

Interleukin (IL)-17A/17R inhibitors
  • Eczematous reactions: The most common cutaneous eruption. It usually occurs within 4 months of initiating treatment. The phenotypes may include generalized atopic dermatitis-like eruptions, facial dermatitis, and/or dyshidrotic eczema. Ixekizumab appears to be the most common culprit, but it has also been reported in patients on secukinumab.
  • Other reactions: psoriasiform eruption, sarcoidosis, alopecia areata, lichenoid eruption, pyoderma gangrenosum, Behçet syndrome, hidradenitis suppurativa, granuloma annulare, lupus-like reaction, vitiligo, erythema multiforme, bullous pemphigoid, and pemphigus.

IL-23 (p19) inhibitors
  • Eczematous reactions: May occur 2.5-3 months after initiation of treatment. It is reported in patients on guselkumab only.

IL-12/23 (p40) inhibitor (ustekinumab)

IL-4Rα inhibitor (dupilumab)
  • Psoriasiform reactions: This usually happens during the first year of therapy. Phenotypes may include plaque type and, less commonly, erythrodermic, guttate, palmoplantar, and scalp psoriasis.
  • Eczematous dermatitis: This may present as localized dermatitis with a predilection for the face, periocular, and neck regions. It usually occurs within 6 months of therapy.
  • Other reactions: alopecia areata, face / neck dermatitis, sarcoidosis-like reaction, and rosacea.


L27.0 – Generalized skin eruption due to drugs and medicaments taken internally

28926001 – Eruption caused by drug

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Last Reviewed:06/19/2022
Last Updated:07/12/2022
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Adverse cutaneous reactions to targeted biologic therapies
A medical illustration showing key findings of Adverse cutaneous reactions to targeted biologic therapies (Eczematous dermatitis)
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