Systematic Review of Eczema in Plaque Psoriasis Treated With Biologic Agents

Atopic eczema is potentially under recognized in patients with plaque psoriasis undergoing biologic therapy and can have a significant effect on patient management, according to results of a systematic review published in the Journal of the European Academy of Dermatology and Venereology.  

In th systematic review, researchers collected and evaluated studies from PubMed, Embase, and Medline that reported “eczema,” “dermatitis,” or variations of these terms as an adverse reaction to biologic therapy for chronic plaque psoriasis. Researchers also included studies in which patients received biologic therapy for other diseases in concurrence with plaque psoriasis. After eliminating studies that did not meet inclusion criteria, researchers extracted data, following the PRISMA flow diagram during their discussion of cited publications.

Researchers screened a total of 8519 records and excluded articles unrelated to eczema and psoriasis (n=8463). Of the remaining 56 eligible articles, 32 were excluded for reasons including not reporting eczema as an adverse event, not specifying the number of eczema cases, or not identifying an underlying diagnosis. In the final quantitative synthesis, researchers selected 24 studies for review.

Researchers found that phenotypic eczema was reported as a cutaneous adverse event (CAE) by patients with psoriasis who underwent biologic therapy. Patients in 46% and 38% of studies reported incidences of atopy and eosinophilia or elevated immunoglobulin E, respectively. Although the studies identified the prevalence of eczema, eczema was not investigated as an adverse event in patients with plaque psoriasis.

Although researchers found that individual case data might suggest an association between biologic agents and the development of eczema, the results are anecdotal. Researchers of a case report from the Danish biologic agents registry noted that 26.1% (n=419) of patients with rheumatology who started on infliximab or etanercept developed eczema. Investigators of a cohort study in Belgium stated that 23.5% of patients with inflammatory bowel disease given tumor necrosis factor (TNF) alpha inhibitor biologic agents did develop eczema. However, a control was absent in both studies, so researchers could not declare an association between the amount of biologic exposure and the frequency of eczema.

Using the Naranjo Adverse Drug Reaction Probability Scale, researchers were unable to prove causation. Seventy-one percent of patients in this review noted that their eczema improved when they discontinued biologic therapy. Investigators of one study identified that 44% of patients with inflammatory bowel disease who had a prior history of atopy developed eczema after receiving TNF-alpha inhibitor therapy. These reports suggest that CAEs are more prevalent in patients with a genetic predisposition to eczema.

Researchers also found that biologic agents used to treat psoriasis are not as effective  atopic eczema as seen in trials of ustekinumab and secukinumab exhibiting no significant improvement in patient symptoms. Two other studies detected a high concentration of “Th1/Th17 cells and related cytokine products whereas eczema lesions contain mostly Th2 cells and IL-13” in patients with CAE and plaque psoriasis. Other researchers attributed plaques in psoriasis to antigens such as leucine-17 and cathelicidin leucine.

One study limitation is the recent changes made to the diagnostic criteria for atopic eczema, which captures the full spectrum of eczema phenotypes but excludes mentions of psoriasis. According to researchers, these restrictions make it difficult to diagnose atopic eczema in future studies. Furthermore, there is not enough research on CAE mechanisms caused by biologics other than TNF-alpha inhibitor due to their relatively new introduction into psoriasis therapeutics.

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The researchers concluded that, after reviewing multiple reports of patients with plaque psoriasis who developed CAEs after biologic treatments, eczema is still an under-recognized CAE that has “a significant impact on patient management.” Therefore, a comprehensive observational study is needed to address whether there is “a statistical correlation between biologic use and the development of eczema” among populations with psoriasis. They recommend that medical practitioners conduct studies on the genetic factors predisposing patients with psoriasis to eczema and other CAEs to gain a better understanding of the molecular mechanisms and genetic factors contributing to the diseases.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

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Al-Janabi A, Foulkes AC, Mason K, Smith CH, Griffiths CEM, Warren RB. Phenotypic switch to eczema in patients receiving biologics for plaque psoriasis: a systematic review [published online January 30, 2020]. J Eur Acad Dermatol Venereol. doi: 10.1111/jdv.16246