Letter to the Editor
Cutaneous lupus erythematosus induced by the treatment with tumor necrosis factor antagonists
Lupus eritematoso cutáneo inducido por la terapia biológica con antagonistas del factor de necrosis tumoral
Walter Alberto Sifuentes Giraldo
, María Ahijón Lana, Mónica Vázquez Díaz
Corresponding author
Servicio de Reumatología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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In connection with more recently introduced anti-TNF agents, certolizumab and golimumab, a case of induced LE has been described with the first<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and one subacute cutaneous LE exacerbation has been related to the second.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Considering the high prevalence of autoantibodies and the large number of patients treated, one would expect a higher frequency of induced LE. One probable explanation for this discrepancy is that the type of autoimmune response induced by anti-TNF agents is mainly restricted to nonpathogenic IgM or IgA isotypes, and although the main reactivity is anti-DNA, it is rare to develop other LE related antibodies, such as anti-ENA or hypocomplementemia. In addition, the titles of anti-DNA IgM tend to fluctuate over time and disappear quickly after removal of the drug.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Identified risk factors for the development of LE during anti-TNF treatment are advanced age and the presence of increased baseline anti-DNA, but not of ANA.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Another factor that could influence this is the underlying disease. Although the production of autoantibodies is similar among the different diseases treated with these agents, most cases have been described in Ra patients, as evidenced by a review of Costa et al.,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> who found that of 33 published cases of induced LE due to anti-TNF drugs, 76% of patients had RA. The frequency with which these cases appear in the literature contrasts to those described in RA clinical trials with long-term follow up, so it should be noted that these cases are generally based on retrospective observations that often lack serological data prior to starting anti-TNF therapy and there may be some overlap of RA and LE before treatment.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">LE cases induced by anti-TNF comply with 4 or more ACR classification criteria in 40%, 3 criteria in 21%, and 2 or less in 39%.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Up to 67% of cases have cutaneous manifestations,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> corresponding generally to maculopapular, pruritic erythematous rash affecting photosensitive areas, as mentioned by the authors,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> however, the spectrum is much broader. Both LE-specific lesions (cutaneous acute, subacute and discoid), and other nonspecific findings including urticarial lesions, scarring, alopecia and purpura may occur.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Within difficult to classify cutaneous LE lesions, there has also been published cases of LE tumidus and lupus perniosis (LP) induced by anti-TNF. LE tumidus is characterized by the appearance of papules on exposed areas, erythematous plaques or nodules without other associated epidermal changes; one of the cases found in the literature occurred with infliximab and adalimumab<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> in another,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> both in RA patients. Our group conducted a review of 5 cases of LP associated with anti-TNF,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> a rare form of cutaneous LE characterized by papules or plaques with erythematous violaceous acral distribution that simulate ischemic injury. Four of these cases occurred in patients with RA and one in ankylosing spondylitis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In summary, although induced LE is a rare adverse event seen during anti-TNF treatment, it is important to have in mind because of its varied clinical expression, especially on the skin, and to identify those cases that actually are due to this entity, given the trend that may lead to overdiagnosis.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sifuentes Giraldo WA, et al. Lupus eritematoso cutáneo inducido por la terapia biológica con antagonistas del factor de necrosis tumoral. Reumatol Clin. 2013. <span class="elsevierStyleInterRef" id="intr0005" href="doi:10.1016/j.reuma.2013.02.002">http://dx.doi.org/10.1016/j.reuma.2013.02.002</span>.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Skin lesions and treatment with tumor necrosis factor alpha antagonists" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.V. Hernandez" 1 => "M. Meineri" 2 => "R. 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Vazquez Diaz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10067-011-1924-x" "Revista" => array:6 [ "tituloSerie" => "Clin Rheumatol" "fecha" => "2012" "volumen" => "31" "paginaInicial" => "563" "paginaFinal" => "568" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22207249" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000000900000004/v1_201307160008/S2173574313000701/v1_201307160008/en/main.assets" "Apartado" => array:4 [ "identificador" => "8400" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000000900000004/v1_201307160008/S2173574313000701/v1_201307160008/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574313000701?idApp=UINPBA00004M" ]
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| 2023 November | 36 | 28 | 64 |
| 2023 October | 32 | 27 | 59 |
| 2023 September | 67 | 36 | 103 |
| 2023 August | 33 | 15 | 48 |
| 2023 July | 30 | 27 | 57 |
| 2023 June | 38 | 18 | 56 |
| 2023 May | 33 | 24 | 57 |
| 2023 April | 23 | 10 | 33 |
| 2023 March | 40 | 23 | 63 |
| 2023 February | 56 | 26 | 82 |
| 2023 January | 30 | 15 | 45 |
| 2022 December | 55 | 33 | 88 |
| 2022 November | 38 | 16 | 54 |
| 2022 October | 42 | 27 | 69 |
| 2022 September | 31 | 31 | 62 |
| 2022 August | 37 | 37 | 74 |
| 2022 July | 25 | 36 | 61 |
| 2022 June | 43 | 30 | 73 |
| 2022 May | 31 | 44 | 75 |
| 2022 April | 38 | 24 | 62 |
| 2022 March | 36 | 44 | 80 |
| 2022 February | 44 | 35 | 79 |
| 2022 January | 27 | 23 | 50 |
| 2021 December | 24 | 36 | 60 |
| 2021 November | 30 | 35 | 65 |
| 2021 October | 42 | 32 | 74 |
| 2021 September | 29 | 36 | 65 |
| 2021 August | 40 | 30 | 70 |
| 2021 July | 28 | 25 | 53 |
| 2021 June | 29 | 33 | 62 |
| 2021 May | 30 | 22 | 52 |
| 2021 April | 87 | 63 | 150 |
| 2021 March | 45 | 21 | 66 |
| 2021 February | 37 | 21 | 58 |
| 2021 January | 19 | 19 | 38 |
| 2020 December | 28 | 11 | 39 |
| 2020 November | 33 | 11 | 44 |
| 2020 October | 14 | 9 | 23 |
| 2020 September | 32 | 13 | 45 |
| 2020 August | 16 | 19 | 35 |
| 2020 July | 16 | 13 | 29 |
| 2020 June | 32 | 14 | 46 |
| 2020 May | 16 | 11 | 27 |
| 2020 April | 19 | 12 | 31 |
| 2020 March | 11 | 9 | 20 |
| 2020 February | 1 | 0 | 1 |
| 2020 January | 1 | 0 | 1 |
| 2019 April | 2 | 0 | 2 |
| 2019 January | 1 | 0 | 1 |
| 2018 May | 4 | 0 | 4 |
| 2018 April | 35 | 9 | 44 |
| 2018 March | 48 | 7 | 55 |
| 2018 February | 26 | 0 | 26 |
| 2018 January | 35 | 8 | 43 |
| 2017 December | 27 | 3 | 30 |
| 2017 November | 37 | 8 | 45 |
| 2017 October | 31 | 7 | 38 |
| 2017 September | 35 | 7 | 42 |
| 2017 August | 44 | 15 | 59 |
| 2017 July | 32 | 11 | 43 |
| 2017 June | 39 | 18 | 57 |
| 2017 May | 58 | 8 | 66 |
| 2017 April | 44 | 4 | 48 |
| 2017 March | 38 | 56 | 94 |
| 2017 February | 37 | 6 | 43 |
| 2017 January | 36 | 3 | 39 |
| 2016 December | 69 | 18 | 87 |
| 2016 November | 44 | 1 | 45 |
| 2016 October | 69 | 14 | 83 |
| 2016 September | 79 | 8 | 87 |
| 2016 August | 56 | 5 | 61 |
| 2016 July | 40 | 7 | 47 |
| 2016 May | 1 | 10 | 11 |
| 2016 February | 1 | 0 | 1 |
| 2016 January | 1 | 0 | 1 |
| 2015 December | 2 | 0 | 2 |
| 2015 October | 1 | 11 | 12 |
| 2015 August | 1 | 0 | 1 |
| 2015 July | 23 | 6 | 29 |
| 2015 June | 36 | 10 | 46 |
| 2015 May | 40 | 18 | 58 |
| 2015 April | 30 | 13 | 43 |
| 2015 March | 24 | 7 | 31 |
| 2015 February | 33 | 5 | 38 |
| 2015 January | 34 | 6 | 40 |
| 2014 December | 39 | 8 | 47 |
| 2014 November | 22 | 8 | 30 |
| 2014 October | 28 | 9 | 37 |
| 2014 September | 26 | 6 | 32 |
| 2014 August | 33 | 9 | 42 |
| 2014 July | 39 | 11 | 50 |
| 2014 June | 56 | 12 | 68 |
| 2014 May | 52 | 15 | 67 |
| 2014 April | 49 | 13 | 62 |
| 2014 March | 58 | 13 | 71 |
| 2014 February | 44 | 5 | 49 |
| 2014 January | 39 | 12 | 51 |
| 2013 December | 38 | 6 | 44 |
| 2013 November | 27 | 11 | 38 |
| 2013 October | 35 | 12 | 47 |
| 2013 September | 29 | 13 | 42 |
| 2013 August | 69 | 31 | 100 |
| 2013 July | 28 | 14 | 42 |
Show all
