Alternative Biologic Therapies for TNFα-Induced Paradoxical Psoriasis in Inflammatory Bowel Disease

When treating patients with IBD and PXP, collaboration between dermatologists and gastroenterologists is key.

A recently published study aimed to evaluate the efficacies of different biologic therapies in treating tumor necrosis factor alpha (TNFα)-induced paradoxical psoriasis (PXP) in addition to controlling inflammatory bowel disease (IBD) symptoms. To review the study findings, Jean S. McGee, MD, PhD, discussed with The Dermatologist how the results may establish collaborations between dermatologists and gastroenterologists intreating patients with IBD and PXP.

The Dermatologist: How can physicians work with their patients to manage both TNFα-induced PXP and IBD symptoms?

Dr McGee: Switching to an alternative biologic therapy to treat TNFα-induced PXP in patients with IBD carries a risk of potentially worsening IBD. I often find patients with IBD tend to be sophisticated in their understanding of the disease. Therefore, involving patients in the discussion and getting their buy-in for any therapy initiation are essential. Some may have struggled to achieve control of their IBD, and they may be hesitant to change their IBD treatment regimen. By collaborating with both patients and their gastroenterologists, dermatologists should entertain all treatment options that can address the skin reaction while maintaining gastrointestinal (GI) control at the same time. In certain situations, no intervention should be considered as an ideal treatment of choice.

The Dermatologist: According to your study, ustekinumab demonstrates significant efficacy intreating TNFα-induced PXP and controlling IBD symptoms. How did ustekinumab compare with other biologics that were reviewed?

Dr McGee: Our study showed that switching to ustekinumab demonstrates superior efficacy in treating TNFα-induced PXP as compared with switching to another anti-TNFα agent. This is perhaps not surprising given the likely class effect of anti-TNF in inducing PXP.  Additionally, our study showed that switching to ustekinumab maintained complete and partial remission of IBD in 80% of the reported cases. However, at this time, we cannot claim therapeutic superiority of ustekinumab over newer biologics, such as vedolizumab and secukinumab. We simply do not have enough use and outcomes data for these newer agents in this subset of IBD patients. Therefore, more robust comparative studies are needed in the future to answer this question.

The Dermatologist: How can these findings help establish collaborations between dermatologists and gastroenterologists in treating these patients?

Dr McGee: Despite one-third of patients with IBD developing skin lesions at some point during the course of their disease, we do not see much collaboration between dermatology and gastroenterology in the way of established interdisciplinary clinics at academic centers. Our study aimed to describe clinical outcomes of both the skin and the gut when switching to an alternative biologic therapy to treat TNFα-induced PXP. We learned that there is a lack of interdisciplinary investigations in this field. By collaborating and comanaging these patients with gastroenterologists, we can start to generate outcomes data that address the skin-gut axis and begin to offer evidence-based medicine to our patients with IBD.

The Dermatologist: What other pearls would you like to share regarding switching to alternative biologic therapies in patients with IBD and TNFα-induced PXP?

Dr McGee: First, it is important to be aware that TNFα-induced PXP can take over a year to develop after the therapy initiation. In our study, the average therapy duration with anti-TNFα agents was 18.75 months. Therefore, taking a thorough GI treatment history in patients with IBD can help you recognize and correctly diagnose TNFα-induced PXP. Second, it is helpful to differentiate certain manifestations of IBD such as perianal fistula in Crohn disease, which is a challenging condition for gastroenterologists to treat and maintain remission. Current gold standard medical treatment for this condition is anti-TNFα therapy. It is noteworthy from our study that switching to another anti-TNFα agent within the same class still demonstrated some clinical improvement of TNFα- induced PXP, albeit significantly less effectively compared with switching to a different class. It is also notable that newer biologic agents such as vedolizumab have demonstrated efficacy in Crohn disease with perianal fistula. Therefore, for this special subset of patients with IBD, it is especially important to collaborate with gastroenterologists to decide on the best treatment course that does not aggravate their perianal manifestation.

Reference
Revankar R, Patel H, Rojas M, Walsh S, McGee JS. Systematic review of TNFα-induced paradoxical psoriasis: treatment outcomes of switching to alternative biologic therapies in inflammatory bowel disease patients. J Dermatolog Treat. Published online October 18, 2022. doi:10.1080/09546634.2022.2133533