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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

Synopsis

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.

Codes

ICD10CM:
L27.0 – Generalized skin eruption due to drugs and medicaments taken internally

SNOMEDCT:
28926001 – Eruption caused by drug

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

Best Tests

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Management Pearls

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Therapy

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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References

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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)
Copyright © 2022 VisualDx®. All rights reserved.