Paradoxical Psoriasis and Alopecia Areata After the Use of Anti-TNF in a Patient With Crohn's Cisease

Document Type

Conference Proceeding

Publication Date

10-1-2024

Publication Title

Am J Gastroenterol

Abstract

Introduction: Autoimmune reactions to anti-tumor necrosis factor (TNF) therapy present a clinical challenge while managing inflammatory bowel disease (IBD). Among these reactions, psoriasis and alopecia can occur as extraintestinal manifestation and due to immunosuppressive medication. We aim to highlight the complexity of autoimmune responses triggered by anti-TNF therapy in a patient with Crohn's disease who developed alopecia and psoriasis of the scalp. Case Description/Methods: A 20-year-old man patient was diagnosed with Crohn's disease after experiencing abdominal cramps, rectal pain, and bleeding. Colonoscopy showed aphthous ulcerations and severe inflammation in the terminal ileum. He was started on infliximab, which improved his symptoms. A year and a half later, his symptoms started to recur, requiring increased dosages. Four months later, the patient reported hair loss. Dermatologists saw the patient and noticed psoriasiform changes on the scalp and ears, and a biopsy showed psoriatic alopecia and alopecia areata features suggestive of anti-TNF alpha related alopecia. Treatments including Triamcinolone injections, clobetasol, and calcipotriene failed to alleviate symptoms. Ultimately, medication was changed to Ustekinumab, which improved his hair loss and Crohn's symptoms, further supporting the diagnosis of anti-TNF alpha-related alopecia. Discussion: The association between anti-TNF-α agents and onset of psoriasiform skin eruptions, and the paradoxical nature of these reactions are well described in the literature. The proposed mechanism relies on the role of IFNγ in the pathogenesis of psoriasis, as blocking TNFa leads to uncontrolled production of IFNγ contributing to the skin eruption. One Meta-Analysis described 134 patients who developed alopecia with IBD therapy. Of those, 78 were on anti-TNF-α therapy. Psoriatic Alopecia was the most reported (n = 41), followed by Alopecia Areata (n = 19), and psoriatic alopecia with alopecia areata features. (n = 3). Diagnosis criteria include absence of psoriasis history, alopecia plaque(s) on the scalp, and psoriasiform rash elsewhere after starting treatment. Our patient met the criteria, with hair regrowth after stopping infliximab. Differentiating these reactions from primary psoriatic alopecia/alopecia areata is important as it affects our management. Lastly, it is important to collaborate in a multidisciplinary approach involving gastroenterology and dermatology when caring for our IBD patient community.

Volume

119

Issue

10

First Page

S2546

Last Page

S2547

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