Anti-TNF-alpha-induced eruptions
Alerts and Notices
Synopsis
Several paradoxical cutaneous eruptions have been described with anti-TNF-alpha use, including:
- Injection site reactions
- Infusion reactions (with infliximab) – Both an acute hypersensitivity reaction within the first 2 hours and a delayed-type hypersensitivity reaction 1-14 days after the infusion.
- Cutaneous infections – Various types of viral, bacterial, and fungal infections have been reported. Patients who are immunosuppressed, have other comorbidities, and/or are on higher doses of anti-TNF-alpha therapies may be at higher risk for infections.
- Psoriasis – New-onset or exacerbated psoriasis has been reported. Palmoplantar pustular psoriasis is a common presentation, but plaque psoriasis is also reported.
- Nonmelanoma skin cancer (NMSC) – The risk of NMSC may be increased, especially in those who are immunosuppressed.
- Lupus-like syndrome – More common in patients who receive etanercept or infliximab. It typically resolves after anti-TNF-alpha therapy is stopped.
- Lichen planus-like eruptions
- Granulomatous reactions, including granuloma annulare and cutaneous and systemic sarcoidosis
- Cutaneous vasculitis – The risk appears to be higher in patients with rheumatoid arthritis.
Related topics: cutaneous adverse effects of anti-PD-1 and anti-PD-L1 therapy, immune-related adverse effects
Codes
ICD10CM:L27.0 – Generalized skin eruption due to drugs and medicaments taken internally
SNOMEDCT:
28926001 – Eruption caused by drug
Look For
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
The differentials for different cutaneous reactions are listed in the following diagnoses:- Injection site reaction – eczematous dermatitis
- Infusion reaction – drug-induced erythroderma, urticaria, exanthematous drug eruption, atopic dermatitis, pityriasis rubra pilaris
- Psoriasis
- NMSCs – basal cell carcinoma, squamous cell carcinoma
- Lupus-like syndrome – systemic lupus erythematosus
- Erythema multiforme
- Stevens-Johnson syndrome / toxic epidermal necrolysis
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.Subscription Required
References
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Last Reviewed:12/19/2017
Last Updated:02/04/2021
Last Updated:02/04/2021
Anti-TNF-alpha-induced eruptions