Paradoxical Psoriasis — SCE Rheumatology MCQ

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ModerateSpondyloarthropathyParadoxical PsoriasisSCE Rheumatology

A 55-year-old man with axSpA on Adalimumab develops paradoxical new-onset psoriasis on his scalp and trunk. He has never had psoriasis before. What is the most appropriate initial management?

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Correct answer: C — Treat the psoriasis topically while continuing Adalimumab

Paradoxical psoriasis is a recognised adverse effect of anti-TNF therapy and can present as new-onset psoriasis in patients without prior history. BSR guidelines recommend attempting topical treatment (potent topical steroids, vitamin D analogues) while continuing the anti-TNF if the axSpA is well controlled. If psoriasis is severe or refractory to topical therapy, switching biologic class (to an IL-17 inhibitor such as Secukinumab) is appropriate. Switching within the TNF class may not resolve the paradox.

Reference: BSR 2019 biologic safety guidelines; Brown G et al 2015 paradoxical psoriasis