Adverse cutaneous reactions to targeted biologic therapies
The following reactions have been reported:
- Psoriasiform eruptions: Most common paradoxical eruption. Patients may present with new-onset psoriasis or changes in the preexisting morphology. Plaque type and palmoplantar psoriasis are the most common phenotypes. Inverse, guttate, generalized / pustular, and psoriatic alopecia-like reactions have also been reported. Infliximab is the most common culprit.
- Lupus-like reactions: This is a rare reaction. Patients may present with systemic lupus erythematosus with renal involvement, lupus-like syndromes, or isolated cutaneous lupus. Infliximab is the most common culprit, followed by adalimumab and etanercept.
- Sarcoidosis-like and other granulomatous reactions: This is a rare reaction with potential pulmonary and cardiac involvement. In addition, granuloma annulare and interstitial granulomatous drug reaction may also occur. Etanercept is the most common culprit.
- Other reactions: alopecia areata, vitiligo, hidradenitis suppurativa, lichenoid eruption, bullous pemphigoid, dermatomyositis, and pyoderma gangrenosum.
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)
- Psoriasiform eruptions: Usually occur within 3 months of treatment.
- Other reactions: vitiligo, alopecia areata, eczematous dermatitis, bullous pemphigoid, sarcoidosis-like reaction, lupus-like reaction, morphea, hidradenitis suppurativa, frontal fibrosing alopecia, Wells syndrome, erythema annulare centrifugum, and linear IgA bullous dermatoses.
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
- Exanthematous eruption: drug rash to other agents, viral exanthems, psoriasis, allergic contact dermatitis, irritant contact dermatitis, tinea corporis, pityriasis rosea, seborrheic dermatitis, lichen simplex chronicus, scabies, pityriasis rubra pilaris, secondary syphilis, glucagonoma syndrome, pellagra, mycosis fungoides
- Psoriasiform eruption: atopic dermatitis, contact dermatitis, lichen planus, lichen simplex chronicus, drug rash to other agents, tinea corporis, subacute cutaneous lupus erythematosus, pityriasis lichenoides chronica, lymphomatoid papulosis, pityriasis rubra pilaris, secondary syphilis, mycosis fungoides, erythema annulare centrifugum, extramammary Paget disease, pityriasis rosea, crusted scabies, sarcoidosis, reactive arthritis, acrokeratosis paraneoplastica