Case & review
Lichen planus–like eruptions: An emerging side effect of tumor necrosis factor-α antagonists

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As tumor necrosis factor (TNF)-α inhibitors gain wider use in clinical practice, it is becoming increasingly evident that these potent immunosuppressants can also induce inflammatory reactions. We present two cases of lichen planus–like eruptions after infliximab and adalimumab therapy for psoriasis, and review the literature on this phenomenon. Eleven cases of lichen planus or lichenoid drug eruptions have been previously reported in patients taking TNF-α inhibitors, in addition to several cases of psoriasiform eruptions with a lichenoid histology. Because TNF-α has been implicated in the pathogenesis of lichen planus, induction of lichenoid reactions by TNF-α inhibition is somewhat unexpected. We consider potential immunologic mechanisms, and suggest that TNF-α inhibition may precipitate lichenoid reactions through disruption of a delicate balance between TNF-α and interferon-α in susceptible patients.

Section snippets

Case 1

A 55-year-old male construction worker began infliximab for treatment of severe psoriatic arthritis and psoriasis affecting 5% of his body surface area. Treatment with infliximab reduced joint pain and swelling, leading to significant functional improvement. His skin improved except for trace residual plaques on the elbows and knees and a persistent lesion in the gluteal fold. His medical history was otherwise notable for hypertension, hypercholesterolemia, erectile dysfunction, and chronic

Discussion

We describe two patients who developed LP-like eruptions while on a TNF-α inhibitor for the treatment of psoriatic disease. Eleven similar cases have been previously reported in 10 patients,10, 11, 12, 13, 14, 15, 16, 17 including one patient who developed lichenoid reactions to both adalimumab and lenercept. Key features of these 13 eruptions in 12 patients are summarized in Table I. Lichenoid interface dermatitis was confirmed by histology in all cases.

The 12 patients were clinically diverse:

Conclusion

In summary, a growing body of evidence suggests that TNF-α inhibitors can trigger a wide variety of inflammatory disease states, including LP-like cutaneous and mucosal eruptions. Lichenoid reactions can occur within weeks of starting therapy, or may be delayed many months. Fortunately, these eruptions have a good prognosis. Some patients recover completely. Those who do not clear have shown at least partial improvement. Whether lichenoid eruptions are an indication to stop TNF-α inhibitor

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  • Cited by (0)

    Supported by a generous grant from Ms Joan Fabry. Tufts Medical Center has received educational/research grants from Centocor, Amgen, Wyeth, Immune Control, Celgene, Incyte, and Abbott.

    Disclosure: Almost all of Dr Gottlieb's income is paid to her employer. Dr Gottlieb has speakers' bureau memberships with Amgen Inc and Wyeth Pharmaceuticals. Dr Gottlieb has current consulting/advisory board agreements with Amgen Inc, Centocor Inc, Wyeth Pharmaceuticals, Celgene Corp, Bristol Myers Squibb Co, Beiersdorf Inc, Warner Chilcott, Abbott Laboratories, Roche, Sankyo, Medarex, Kemia, Celera, TEVA, Actelion, UCB, Novo Nordisk, Almirall, Immune Control, RxClinical, Dermipsor Ltd, Medacorp, DermiPsor, Can-Fite, Incyte, and Corgentech. Ms Fabry is a patient of Dr Gottlieb's and gave an unrestricted grant to support psoriasis research. Dr Massarotti receives consulting/honoraria from Bristol Myers Squibb, UCB, Genentech, Abbott, and PAI. Dr Bush has received research funding from Centocor. Mr Asarch, and Drs Lee, Masterpol, Scheinman, and Stadecker have no conflicts of interest to declare.

    Case 1 was presented at a meeting of the New England Dermatological Society at Tufts Medical Center, Boston, MA, on December 1, 2007.

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