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Paradoxical Psoriasis Switching — SCE Rheumatology MCQ

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HardRheumatology PharmacologyParadoxical Psoriasis SwitchingSCE Rheumatology

A 60-year-old man with RA develops a psoriasiform skin eruption on his scalp palms and soles while on Adalimumab. His dermatologist diagnoses paradoxical psoriasis. If switching biologic class what options are available?

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Correct answer: A — Consider switching to a non-TNF biologic (Abatacept Tocilizumab Rituximab or JAK inhibitor) as paradoxical psoriasis may recur with any TNF inhibitor

Paradoxical psoriasis can recur with any anti-TNF agent (class effect) so switching within the TNF class may not resolve the problem. If topical treatment fails and the psoriasis is significant switching to a different biologic mechanism (Abatacept Tocilizumab Rituximab or a JAK inhibitor) eliminates the TNF-blockade-mediated interferon-alpha excess that drives paradoxical psoriasis. However some patients do improve with a switch within the TNF class. The decision should be individualised considering RA disease control psoriasis severity and patient preferences. Dermatology co-management is recommended.

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