Successful Management of Anti-TNF-Induced Psoriasis Despite Continuation of Therapy in a Pyoderma Gangrenosum Patient

Pyoderma gangrenosum (PG) is a rare, ulcerating, inflammatory skin disease that commonly arises at sites of minor trauma, a phenomenon known as pathergy. Although its etiology is mostly unknown, T cell activation, abnormal neutrophil migration, and tumor necrosis factor (TNF), and interleukin (IL)-17 signaling appear to play major roles in pathogenesis.^1-3

Despite their therapeutic efficacy in psoriasis, TNF inhibitors, such as adalimumab, have been implicated in paradoxical anti-TNF-induced psoriasis. In these cases, it is commonly thought that the offending TNF inhibitor should be immediately discontinued. However, we demonstrate that anti-TNF agents can be continued for treatment of underlying disease in the setting of paradoxical psoriasis. We also demonstrate the utility of adjunct treatment, specifically secukinumab and methotrexate, in the respective induction and maintenance of remission from anti-TNF-induced psoriasis.

A 60-year-old woman with a history of severe, relapsing PG requiring multi-drug therapy presented with an ulcer at the site of a recent skin biopsy (Figure 1a). Her treatment regimen for PG included adalimumab 40 mg twice monthly and a multidrug combination of mycophenolate mofetil and cyclosporine, which she had previously responded well to. Upon presentation, adalimumab was increased to 40 mg weekly alongside adjuvant therapy, which resulted in remission of her PG flare (Figure 1b). She then continued this regimen as maintenance therapy (Figure 2).