Melissa P. Zundell BS, Alice B. Gottlieb MD PhD, Roselyn Stanger MD
Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY
Abstract
Paradoxical reactions to biologic agents used in the treatment of psoriasis are rare but have been reported with tumor necrosis factor (TNF) blockers and, more recently, with interleukin (IL)-17A inhibitors. Secukinumab, an IL-17A inhibitor, is an effective treatment for moderate-to-severe plaque psoriasis but has been implicated in the development or exacerbation of eczematous-like reactions in rare cases. We present a patient with a history of plaque psoriasis who developed an eczematous eruption after four months of secukinumab therapy, necessitating systemic intervention for adequate control. Five months after a loading dose of dupilumab, the patient appeared in the clinic with the return of classic, thick psoriatic plaques, affecting 15% BSA. The patient declined further treatment and was subsequently lost to follow-up despite multiple attempts to contact her. This case adds to the limited, but growing body of knowledge on IL-17 blocker-induced eczematous reactions and underscores the need for careful monitoring and prompt recognition of this adverse event in patients receiving this class of drugs.
Paradoxical reactions refer to unexpected adverse events that occur during or after treatment with a medication that is contradictory to the medication's intention. In dermatology, these reactions have been observed with various systemic therapies, including biologic agents used to treat psoriasis. While tumor necrosis factor (TNF) blockers are most commonly associated with paradoxical reactions, more recent biologics, such as interleukin (IL)-17A inhibitors, have also been implicated. Although effective in treating moderate-to-severe plaque psoriasis, secukinumab, an IL-17A inhibitor, has been reported to cause the development or exacerbation of eczematous-like reactions in rare cases.1 The appearance of these reactions is poorly understood and not well-documented in the literature. In this report, we present the case of a patient with a history of plaque psoriasis who developed an eczematous eruption after secukinumab therapy. Our case underscores the importance of recognizing paradoxical reactions and addressing the limited knowledge surrounding their mechanism and management.
CASE
A 45-year-old female with plaque psoriasis on four months of secukinumab therapy presented via teledermatology with an intensely pruritic, 10-day-long rash on the forearms, trunk, and legs. On exam, there were erythematous, crusted papules coalescing into eczematous plaques on the trunk and extremities, particularly severe on the volar surfaces. She was prescribed
