Journal Information
Vol. 15. Issue 6.
Pages e163-e165 (November - December 2019)
Vol. 15. Issue 6.
Pages e163-e165 (November - December 2019)
Letter to the Editor
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Certolizumab Pegol-induced Palmoplantar Pustulosis: A Case Report and Review of the Literature
Pustulosis palmoplantar inducida por certolizumab pegol: presentación de un caso y revisión de la literatura
Lourdes Villalobos-Sánchez
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Corresponding author.
, Carmen Larena-Grijalba, Adela Alía-Jiménez, Walter Alberto Sifuentes-Giraldo
Servicio de Reumatología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Tables (1)
Table 1. Characteristics of the Patients With Certolizumab-induced Psoriasis.
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Dear Editor,

The biological drugs that target tumour necrosis factor α (TNFα) are now widely used to treat rheumatoid arthritis (RA) and other immunomediated inflammatory diseases. Although they have been shown to be highly effective and to have a good safety profile,1 they are also associated with adverse cutaneous events, including psoriasis and psoariasiform lesions.2 We present a patient diagnosed RA who developed palmoplantar pustulosis (PPP) during treatment with certolizumab pegol (CZP), and we also review the published cases of psoriasis induced by this drug.

A 57 year-old male with a history of diabetes mellitus and arterial hypertension was diagnosed RA at the age of 50 years-old due to his polyarthritis in the small joints of the hands, raised acute phase reagents and positivity for rheumatoid factor and anti-cyclic citrullinated peptide antibodies. He was treated at first with methotrexate (maximum dose 20mg/week, subcutaneous), with clinical improvement and good tolerance. However, after 5 years he underwent gradual worsening of the inflammatory symptoms in the hands and persistently high levels acute phase reagents (disease activity measured by DAS28: 5). Due to this it was decided to add CZP (subcutaneous 200mg every 2 weeks), achieving a good response in the joints and analytical results within the first 2 months. After 3 months of anti-TNFα treatment he visited the emergency department due to a sudden outbreak of converging and painless millimetrical pustular lesions on the palms and soles of the feet (Fig. 1), with no signs of infection or lesions in other locations. Biopsy of a palm lesion was histopathologically compatible with PPP. CZP was withdrawn, but methotrexate was maintained, starting topical corticoid therapy with betamethasone cream. The latter was subsequently changed to clobetasol cream with occlusive bandages and laser sessions, and the lesions disappeared completely 4 months after suspending the anti-TNFα. The patient remained in remission after a 6-month observation period, continuing treatment only with subcutaneous methotrexate 25mg/week, without the need to recommence the biological treatment.

Fig. 1.

Appearance of pustular lesions, mainly located on the thenar eminences of both palms (A) and on the medial zone of the soles of the right (B) and left (C) feet, showing a tendency to converge and leaving wide zones of flaking and erythema on the hands.


The appearance of psoriasis de novo or worsening of pre-existing psoriasis is an AE associated with all anti-TNFα drugs, and it may occur at any time (from days until years after the start of treatment), without any variations according to sex or age.2,3 Although it has been described in almost all of the diseases treated with anti-TNFα, up to 75% of cases correspond to inflammatory rheumatological disease.2 A recent meta-analysis that included 216 cases of de novo psoriasis induced by anti-TNFα found the following frequency for each of the following drugs: infliximab 62%, adalimumab 21.8%, etanercept 14.4%, CZP 1% and golimumab 0.5%.3 Rather than reflecting any difference between these drugs, this may be due to the higher number of patient-years of exposure to the first anti-TNFα approved, in comparison with CZP and golimumab, and it is now considered to be a class effect of these drugs.2,3

In our review of the literature (PubMed) we found 9 cases of CZP induced psoriasis, 2 in RA and 7 in Crohn's disease (Table 1). The cases which occurred in RA corresponded to PPP; in the first of these it was a recurrent AE (the first event after etanercept),4 while in the second it appeared de novo and progressed to generalised pustular psoriasis (GPP).5 CZP was withdrawn in both cases and after dermatological treatment the patients showed good clinical evolution of the lesions. All of the cases which arose in Crohn's disease were de novo (3 with CZP as the first anti-TNFα and 3 in which it was the second) and the types of psoriasis they had were: plaque psoriasis (3),6guttata psoriasis (1),7 PPP+plaque psoriasis (1),8 PPP+guttata psoriasis (1)9 and one unspecified type (1).10 In 5 cases CZP was suspended, 4 cases had a good response to topical corticoid therapy and 2 cases also required photochemotherapy and acitretrin.

Table 1.

Characteristics of the Patients With Certolizumab-induced Psoriasis.

Study  Age (years)  Sex  Base disease  PH/FH of psoriasis  Previous treatments  CZP treatment pattern  Type of psoriasis  Time to appearance of induced psoriasis  Evolution 
Shelling et al.4  78  RA  No/no  MTX, ETN  400mg every 2 weeks, sc  PPP  10 weeks with ETN6 weeks with CZP  Improvement following the suspension of CZP and high power topical corticoid treatment 
Koizumi et al.5  71  RA  No/no  MTX, IFX  200mg every 4 weeks, sc  PPPGPP  122 days until the development of PPP157 days until the development of GPP  No response following suspension of CZP and topical corticoid treatmentRapid improvement of the lesions (one week) with oral etretrinate (20mg/day), but without completely disappearing 
Eickstaedt et al.6  14  CD  No/no  IFX  ND  PsoP  29 months with IFX3 months with CZP  Remission of the first outbreak following suspension of IFX topical treatment with triamcinolone and calcipotriene and dressings with acetic acidRemission of the second outbreak after suspension of CZP and topical treatment with hydrocortisone 
  17  CD  No/no  IFX  ND  PsoP  6 months with IFXUnspecified time with CZP  Remission of the first outbreak after suspension of IFX and topical treatment with triamcinolone and hydrocortisoneRemission of the second outbreak after suspension of CZP and treatment with MTX and topical hydrocortisone 
  18  CD  No/no  ADA  ND  PsoP  Unspecified time with ADA6 months with CZP (+MTX)  Remission of the first outbreak after suspension of ADA and topical treatment with hydrocortisone and betamethasoneRemission with topical treatment with flucinolone and calcipotriene 
Fischer et al.7  38  CD  PsoP/no  ND  ND  PsoG  One week until development of PsoG  Remission after suspension of CZP and topical treatment with triamcinoloneStart of IFX and oral PDN for CD, no recurrence of PsoG 
Mocciaro et al.8  42  CD  No/no  MTX, IFX  400mg every 4 weeks, sc  PPP+PsoP  29 weeks until development of PPP  No response after suspension of CZP and treatment with topical corticoidsComplete remission of the lesions with CSA (3mg/kg/day) and oral acitretrin (10mg/day) 
Klein et al.9  26  CD  No/no  ND  ND  PPP+PsoG  4 months until the development of PPP  Initial improvement in pustular lesions with suspension of CZP and oral PDN 30mg/dayImprovement of PsoG with MTX (25mg/week), that had to be changed to 6-MPRecurrence of PPP that improved with UBV phototherapy and topical treatment with betamethasone and calcipotriene 
Protic et al.10  ND  ND  CD  No/no  ND  ND  NE  ND  ND 
The current case  57  RA  No/no  MTX  200mg every 2 weeks, sc  PPP  3 months until development of PPP  Remission after suspension of CZP and topical treatment with betamethasone and clobetasol and laser sessions 

ADA: adalimumab; FH: family history; PH: personal history; RA: rheumatoid arthritis; CSA: cyclosporine A; CZP: certolizumab pegol; CD: Crohn's disease; ETN: etanercept; M: man; IFX: infliximab; W: woman; MTX: methotrexate; ND: no available data; NE: not specified; GPP: generalised pustular psoriasis; PPP: pustulosis palmoplantar; PsoG: psoriasis guttata; PsoP: plaque psoriasis; sc: subcutaneous; UBV: ultraviolet B light.

The types of anti-TNFα-induced psoriasis described the most often in the literature are: plaques 44.8%, PPP 36.3%, GPP 10.9% and guttata 8%.3 The high frequency with which PPP occurs in patients treated with anti-TNFα in comparison with the general population (an incidence of 0.12%) suggests that this is a specific AE of these drugs. Although suspension of the treatment is not always indispensable, severe forms such as PPP and GPP may respond better if the anti-TNFα is withdrawn.6

To conclude, CZP may be associated with the development of induced psoriasis, as is the case with other anti-TNFα drugs, regardless of their indication, and PPP is one of the most frequent forms of presentation.

H. Yamanaka.
TNF as a target of inflammation in rheumatoid arthritis.
Endocr Metab Immune Disord Drug Targets, 15 (2015), pp. 129-134
A.N. Collamer, K.T. Guerrero, J.S. Henning, D.F. Battafarano.
Psoriatic skin lesions induced by tumor necrosis factor antagonist therapy: a literature review and potential mechanisms of action.
Athritis Rheum, 59 (2008), pp. 996-1001
G. Brown, E. Wang, A. Leon, M. Huynh, M. Wehner, R. Matro, et al.
Tumor necrosis factor-α inhibitor-induced psoriasis: systematic review of clinical features, histopathological findings, and management experience.
J Am Acad Dermatol, 76 (2017), pp. 334-341
M.L. Shelling, M. Vitiello, E.L. Lanuti, M. Miteva, P. Romanelli, F.A. Kerdel.
A case of palmoplantar pustulosis induced by certolizumab pegol: new anti-TNF-alpha demonstrates the same class effect.
J Clin Aesthet Dermatol, 5 (2012), pp. 40-41
H. Koizumi, A. Tokuriki, N. Oyama, H. Ido, K. Sugiura, M. Akiyama, et al.
Certolizumab pegol, a pegylated anti-TNF-α antagonist, caused de novo-onset palmoplantar pustulosis followed by generalized pustular psoriasis in a patient with rheumatoid arthritis.
J Dermatol, 44 (2017), pp. 723-724
J.B. Eickstaedt, L. Killpack, J. Tung, D. Davis, J.L. Hand, M.M. Tollefson.
Psoriasis and psoriasiform eruptions in pediatric patients with inflammatory bowel disease treated with anti-tumor necrosis factor alpha agents.
Pediatr Dermatol, 34 (2017), pp. 253-260
R. Fischer, M. DaCunha, A. Rajpara.
Certolizumab-induced guttate psoriasiform dermatitis.
Dermatol Online J, 23 (2017), pp. 10
F. Mocciaro, S. Renna, A. Orlando, M. Cottone.
Severe cutaneous psoriasis after certolizumab pegol treatment: report of a case.
Am J Gastroenterol, 104 (2009), pp. 2867-2868
R.Q. Klein, J. Spivack, K.A. Choate.
Psoriatic skin lesions induced by certolizumab pegol.
Arch Dermatol, 14 (2010), pp. 1055-1056
M. Protic, A. Schoepfer, N. Yawalkar, S. Vavricka, F. Seibold.
Development of psoriasis in IBD patients under TNF-antagonist therapy is associated neither with anti-TNF-antagonist antibodies nor trough levels.
Scand J Gastroenterol, 51 (2016), pp. 1482-1488

Please cite this article as: Villalobos-Sánchez L, Larena-Grijalba C, Alía-Jiménez A, Sifuentes-Giraldo WA. Pustulosis palmoplantar inducida por certolizumab pegol: presentación de un caso y revisión de la literatura. Reumatol Clin. 2019;15:e163–e165.

Copyright © 2017. Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología
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