Skin in the Game: Involving the Dermatologist in Manifestations of IBD

Dermatologic extraintestinal manifestations (EIMs) of inflammatory bowel disease (IBD) were the focus of a presentation by Millie Long, MD, at the Advances in Inflammatory Bowel Disease 2022 virtual regional meeting on March 5.

Dr Long is a gastroenterologist and associate professor at the University of North Carolina School of Medicine at Chapel Hill, and codirector of the Crohn’s and Colitis Foundation Clinical Research Alliance.

Dr Long separated dermatologic involvement into 3 categories: cutaneous disorders linked to inflammation, including pyoderma gangrenosum, erythema nodosum, hidradenitis suppurativa, and cutaneous Crohn disease; paradoxical manifestations to biologics, such as psoriasiform eruptions; and drug-induced cutaneous complications, such as nonmelanoma skin cancer (NMSC) and melanoma.

Pyoderma gangenosum is characterized by rapid development of “one or more painful, purulent ulcers” most commonly seen on the legs, but also in the peristomal areas. While the “violaceous border” is classic, Dr Long stated that lesions on skin of color may be appear differently and providers should be aware of this difference in tone. This manifestation is more common in ulcerative colitis (UC) than Crohn disease (CD), with rates of 5% to 20% and 1% to 2%, respectively. Risk factors include being female and having a higher body mass index. Dr Long said that pathergy is possible in this EIM, meaning when pressure is applied to a lesion, they can progress and worsen. Because of this, a biopsy may even be avoided.

Dr Long shared that for pyoderma gangenosum in her own practice, she often collaborates with the ostomy nurses to ensure that pathergy and pressure are relieved in peristomal sites. For treatment, she opts for “local triamcinolone injections, topical fluticasone spray,” and an optimization of the IBD therapy with an anti-tumor necrosis factor (TNF) agent to control both the IBD and pyoderma gangenosum.

Dr Long stated that erythema nodosum is a more commonly seen EIM, with 4% to 5% occurring in UC and 3% to 10% in CD. This manifestation occurs as “acute tender eruptions of erythematous nodules,” often located on the extensor surfaces of the patient’s extremities. Erythema nodosum will usually parallel the IBD disease activity and “often treating the underlying IBD will resolve erythema nodosum,” Dr Long said. Supportive treatment, such as leg elevation and compression, can aid as well.

Hidradenitis suppurative (HS) often appears as “chronic inflammation marked by recurrent abscess and nodule formation, followed by sinus tract creation and scarring.” It often occurs in the axilla, inguinal area, and perianal region. There is a higher prevalence of IBD in patients with HS than the general population, and a higher prevalence of HS in patients with IBD (6.8% to 10.6%). Risk factors include smoking, obesity, genetic predisposition, and female sex.

For HS, Dr Long emphasized caution in distinguishing this manifestation from perianal CD. “It can obviously look somewhat like perianal Crohn’s disease,” she said, “but it also can involve the axilla. An exam that includes examination of both the groin and perianal region and the axilla can help you to understand if this could actually be hidradenitis rather than perianal disease.”

Dr Long refers to the Hurley staging scale, which stratifies HS into mild, moderate, or severe disease, when determining treatment, and often turns to topical clindamycin or other antibiotics, and optimizes IBD therapy, again, toward an anti-TNF agent.

Cutaneous Crohn Disease presents as “specific granulomatous cutaneous lesions with the same histopathology as CD,” appearing with classic “knife-like” lesions in the perineum. There are 2  types: genital (occurring 56% of the time) and nongenital (44%). The genital presentation tends to affect younger patients, with fissures or ulcers of the labia or scrotum and penis. The nongenital presentation can affect the lower extremities, abdomen, and elsewhere. Dr Long suggested “local triamcinolone injections, topical fluticasone spray,” and, optimization of IBD therapy. For cutaneous CD, this means turning to an anti-TNF agent or an IL-12/23 inhibitor. Dr Long also mentioned that there have been some advances in using hyperbaric oxygen to treat this manifestation, particularly with nonhealing perineal wounds.

Paradoxical manifestations are anti-TNF induced occurrences with a rate of 2% to 20% among patients with IBD. Dr Long pointed out that these manifestations “occur in other autoimmune mediated conditions as well.” While these EIMs appear most commonly during maintenance therapy, they can occur as early as 1 month into treatment. In one retrospective cohort study, looking at 917 patients with IBD who initiated anti-TNF therapy with 3.5 years of follow-up, the most common condition was psoriasiform eczema (30.6%), followed by eczema (23.5%), xerosis cutis (10.6%), and palmoplantar pustulosis (5.3%). These typical occurred at the flexural regions, genitalia, and scalp, but can appear elsewhere.

Risk factors for skin paradoxical manifestations include CD and a higher BMI, with a similar risk profile for both men and women, and smokers and nonsmokers. Patients on immunomodulators and those who had UC had lower risks.

Most of these manifestations can be managed well with conservative treatments, such as “topical emollients, corticosteroids, systemic treatment, or antibiotics and antihistamines.” Dr Long explained that due to the location of lesions, the degree of itching or pain, recurring symptoms, or associated arthralgias, it may be necessary to discontinue the anti-TNF agent.

Dr Long offered a treatment algorithm for skin paradoxical manifestations: First, confirm the diagnosis, conferring with a dermatologist if necessary. Work on any other contributing factors that may exist (smoking cessation and conventional treatments). If there is improvement in the skin condition, continue the anti-TNF therapy, potentially with an immunomodulator. If there is no improvement, evaluate whether the anti-TNF agent has been effective for the patient’s IBD. If not, consider a change in class to ustekinumab. If the anti-TNF agent has been effective, consider an alternate anti-TNF agent. There is “up to a 50% chance of recurrence” of the skin paradoxical manifestation when switching to a different anti-TNF agent. From there, if there is a lack of response or a recurrence of the skin condition, it may be time to initiate ustekinumab.

Dr Long also stressed the importance of maximizing the use of topical corticosteroids when treating these skin paradoxical manifestations, advising to be aware of at least 1 low-, 1 moderate-, and 1 high-potency option.

Skin cancer is also a possible drug-induced complication with IBD. The annual incidence of NMCS is elevated for patients with IBD compared to age-matched controls. This risk is driven by thiopurines, tofacitinib, and potentially, methotrexate. Dr Long stressed the importance of prevention with the use of sunscreen, as the increased risk of NMCS from thiopurine is largely caused by “increased photosensitization of human skin to UV-A light.”

Melanoma also has higher incidence rates among the IBD population than the non-IBD population. Anti-TNF agents are the driving risk for melanoma in IBD. Dr Long advises patients to avoid other behaviors that increase the risk of melanoma.

When it comes to referring patients to a dermatologist, Dr Long suggests doing so when topical, local, and IBD-directive therapy have all been ineffective for the skin condition; when there is a suspected drug reaction; if there is a need for a biopsy; and to collaborate on HS management, such as with laser therapy or off-label treatments. She also highlighted the importance of annual skin exams for those patients on immunosuppressive therapies.

—Allison Casey

For more content from the Advances in Inflammatory Bowel Disease 2022 Regional Meetings, visit our Meeting Newsroom.
 

Reference:
Long M. Skin in the game: When should I refer?. Presented at: Advances in Inflammatory Bowel Disease 2022 Regional Meeting; March 5, 2022; Virtual