Palmoplantar psoriasis in patient treated with TNF- alpha inhibitor - a case report

Treatment of inflammatory rheumatic diseases with TNF-α inhibitors resulted in dramatic improval of clinical outcomes of rheumatic patients. These agents showed the same level of efficacy in other inflammatory diseases such as inflammatory bowel disease and psoriasis. Introduction of new drugs resulted with new spectrum of side effects one of which is paradoxical appearance of psoriatic changes in RA patients treated with TFN-α inhibitors. Thirty eight-years old man has been treated in our institution because of refractory rheumatoid arthritis. He was diagnosed few years earlier at age 30 and since than he has been treated with various regimens of combination therapy which included different DMARD's, glucocorticoids (systemic and intraarticular apllication) and NSAID's. Therapeutic trials with methotrexate (nausea and vomiting), leflunomide (diarrhoea), sulphasalazine (ineffectiveness) were performed in combination together with 0, 25 mg/kg glucocorticoids but side effects of both DMARD's have limited the impact of this drug combination. Due to refractory gonarthritis partial synoviectomy has been performed with transitory effect. Because of the ineffectiveness of used standard combinations of DMARD's and glucocorticoides we have admitted adalimumab in standard dose of 40 mg sc every 2 weeks with excellent effect – all clinical signs and symptoms have diminished, laboratory findings have normalized and so did DAS28. Patient has gradually stopped using all medications which he formerly used. (!). However, after several months patient got squamose skin changes on the palms and foot which have been histologically characterized as palmoplantar psoriasis. Changes which macroscopically appeared like psoriasis have also occured on the nails. Family history of psoriasis was negative and there were no obvious trigger factors known that could induce psoriasis (smoking, infection, drugs). Considering the excellent effect of adalimumab on RA and with patient`s consent, the treatment has continued and the skin lesions were treated with topical preparations with good effect. There are various explanations about etiology of psoriasis in RA patients treated with adalimumab, but neither explain the development of psoriasis in these patients completely. What all of these patients have in common is RA refractory to standard drug combinations and most of them had commonly rare form of psoriasis – the palmoplantar psoriasis. Skin lesions were mild and didn`t indicate the need of RA treatment withdrawal.